Date : 00.00.00
Name of the Patient : Abc Xyzti V. Klmn / F / 47 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 LLE.
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.
There is a left postero-lateral disc herniation at the L4-L5 level with antero-lateral indentation of the thecal sac and left neural foraminal narrowing. A sequestered/extruded disc fragment is seen in the left recess of L5 with impingement of the exiting left L5 nerve root (scans 104.9, 104.10, 106.6, 102.3).
A right paracentral disc herniation is seen at the L5-S1 level with mild indentation upon the right S1 nerve root.
A focal postero-central disc protrusion is noted at the L3-L4 level with anterior indentation of the thecal sac.
The lower lumbar facet joints show mild degenerative changes.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 :
14.0 mm at L1-L2
13.0 mm at L2-L3
11.0 mm at L3-L4
10.0 mm at L4-L5
9.0 mm at L5-S1.
1. A left postero-lateral disc herniation at the L4-L5 level with a sequestered/extruded disc fragment impinging the exiting left L5 nerve root in the left lateral recess of L5.
2. A right paracentral disc herniation at the L5-S1 level with mild indentation upon the right S1 nerve root.
3. A focal postero-central disc protrusion at the L3-L4 level.