Date : 00.00.00
Name of the Patient : Abc Xyzabee Mohd.Ilmn / F / 45 yrs
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE with paresthesias.
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 loss of normal lumbar lordosis and loss of water content of the L4-L5 intervertebral disc.
There is a postero-central and right postero-lateral disc herniation at the L4-L5 level with bilateral neural foraminal narrowing (right more than left) and indentation on the traversing right L5 nerve root. Slight facetal hypertrophy is noted at this level. An anterior disc herniation is seen at the L4-L5 level.
Minimal posterior disc bulges are noted at the L2-L3 and L3-L4 levels.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of 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 S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
14.0 mm at L1-L2
14.0 mm at L2-L3
15.0 mm at L3-L4
11.0 mm at L4-L5
8.0 mm at L5-S1.
A postero-central and a right postero-lateral disc herniation at the L4-L5 level with indentation on the traversing right L5 nerve root with facetal hypertrophy and resultant tight canal at this level.