Date : 00.00.00
Name of the Patient : Abc Xyzukhelmn / M / 54 yrs.
Referred by : Dr. Abc Xyzy.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE in August 0000.
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 L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content with the L5-S1 intervertebral disc being reduced in height.
There is a left paracentral disc herniation with peridiscal osteophytes at the L5-S1 level with indentation upon the S1 nerve roots bilaterally (left more than right).
A diffuse posterior disc bulge is noted at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. Mild ligamentum flavum hypertrophy and right hypertrophic facetal arthropathy is also noted at this level.
A posterior and a left far lateral disc bulge is noted at the L3-L4 level with anterior indentation of the thecal sac and the extraforaminal portion of the left L3 nerve root.
The L3-L4 facet joints show degenerative changes.
Areas of focal fat deposition/hemangiomas with fatty content are seen in the L2 and L4 vertebral bodies.
The rest of 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 S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
11.0 mm at L1-L2
11.0 mm at L2-L3
15.0 mm at L3-L4
17.0 mm at L4-L5
17.0 mm at L5-S1.
As compared to the previous MRI dated 00.00.0000, there is no significant change noted.
Clinical correlation, is however indicated.