Date : 00.00.00
Name of the Patient : Abc Xyzalmn / F / 72 yrs.
Referred by : Dr. Abc Xyzshah / Dr. Abc Xyzdiwala.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE with numbness since 10 days.
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 water content of the lumbar intervertebral discs.
There is a left postero-lateral disc herniation at the L4-L5 level, with left neural foraminal narrowing. A sequestered disc fragment is noted in the right lateral recess of the L5 vertebra with indentation upon the traversing right L5 nerve root.
Minimal posterior disc bulges are noted at the D12-L1 and L3-L4 levels.
Type II degenerative changes are noted within the lumbar vertebral bodies and S1 vertebral body.
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 :
16.0 mm at L1-L2
16.0 mm at L2-L3
13.0 mm at L3-L4
13.0 mm at L4-L5
12.0 mm at L5-S1.
A left postero-lateral disc herniation at the L4-L5 level with a sequestered disc fragment in the right lateral recess of the L5 vertebra indenting the traversing right L5 nerve root.