Date : 00.00.00
Name of the Patient : Abc Xyz Kewalralmn / F / 18 yrs.
Referred by : Dr. Abc Xyzkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 1 month.
M.R.I of the lumbo-sacral spine was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and T2 Weighted axial images.
There is a small right postero-lateral disc protrusion at the L5-S1 level with antero-lateral indentation of the thecal asc and right neural foraminal narrowing. Mild indentation upon the right S1 nerve root is seen. This intervertebral disc shows loss of water content (scans 103.5, 104.3, 106.3, 102.5).
A small posterior disc bulge is identified at the L4-L5 level.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1 level and the thecal sac terminates at the S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
17.0 mm at L1-L2
19.0 mm at L2-L3
17.0 mm at L3-L4
17.0 mm at L4-L5
11.0 mm at L5-S1.
The sacro-iliac joints were screened with 5 mm thick T1 Weighted and 4 mm thick STIR coronal images and which does not reveal any diagnostic feature of note except for subtle fatty changes in the iliac bones.
The MRI features are suggestive of a small right postero-lateral disc protrusion at the L5-S1 level with indentation upon the right S1 nerve root.