sb/ke/rg/nl
Date : 00.00.00
Name of the Patient : Abc XyzKhlmn / F / 35 yrs.
Referred by : Dr. Abc Xyzrdiwalla.
Examination : M.R.I. of the Dorsal & Lumbo-sacral Spines.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE with paresthesias.
EXAMINATION :
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.
The dorsal spine was scanned with 4 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and T2 Weighted axial images.
OBSERVATION :
There is loss of water content of the L4-L5, L5-S1, L2-L3 and some of the dorsal intervertebral discs.
There is slight central wedging of the D12 vertebral body and anterior wedging of the L1 vertebral body without change in signal intensity. Central herniation of the D11-D12 intervertebral disc into the body of D12 is noted. Minimal posterior peridiscal osteophytes are noted at the D12-L1 level.
Small postero-central protruded discs are noted at the L4-L5 and L5-S1 levels.
The visualized dorsal and 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 visualized dorsal spinal cord reveals normal signal intensity. There is no cord compression.
The conus medullaris terminates at the L1-L2 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 :
18.0 mm at L1-L2
14.0 mm at L2-L3
17.0 mm at L3-L4
14.0 mm at L4-L5
14.0 mm at L5-S1.
IMPRESSION :
1. Slight central wedging of the D12 vertebral body and anterior wedging of the L1 vertebral body without change in signal intensity may be the sequelae of previous trauma.
2. Small postero-central protruded discs at the L4-L5 and L5-S1 levels.
3. There is no cord signal alteration or cord compression noted in the dorsal region.