Date : 00.00.00
Name of the Patient : Abc XyzSlmn / M / 38 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with paresthesias since 2-3 months.
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.
A postero-central disc herniation is seen to indent the thecal sac at the L2-L3 level.
A posterior disc bulge is seen to indent the thecal sac at the L3-L4 level. Mild posterior disc bulges are noted at the L4-L5 and L5-S1 levels.
There is a small left postero-lateral disc herniation at the D12-L1 level.
Facetal and ligamentum flavum hypertrophy is noted at the L4-L5 level. Mild facetal hypertrophy is noted in the rest of the lumbar region.
The D12-L1, L2-L3 and L3-L4 intervertebral discs show loss of water content. Hypointense areas on all the pulse sequences within the the D12-L1 intervertebral disc may represent calcium/vacuum phenomena. The L1-L2 and L4-L5 intervertebral discs show mild loss of water content.
- 2 - Scan-00003
A few of the lumbar vertebral bodies show Type II degenerative changes. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1-L2 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 :
15.0 mm at L1-L2
12.0 mm at L2-L3
12.0 mm at L3-L4
12.0 mm at L4-L5
9.0 mm at L5-S1.
The MRI features are suggestive of :
1. A postero-central disc herniation at the L2-L3 level.
2. A small left postero-lateral disc herniation at the D12-L1 level.
3. Facetal and ligamentum flavum hypertrophy at the L4-L5 level.