Date : 00.00.00
Name of the Patient : Abc Xyzdin Alilmn / M / 61 yrs.
Referred by : Dr. Abc Xyzkdawala.
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 L5 vertebra is as marked on the film. Please correlate with plain radiographs.
There is retroplacement of the L5 vertebra over the S1 vertebra. The L5-S1 intervertebral discs shows loss of water content and presence of hypointense areas on all the pulse sequences which may suggest calcium/vacuum phenomena.
Large postero-central and left postero-lateral disc herniations are seen to indent the thecal sac and narrow the left neural foramen at the L5-S1 level. Also seen is indentation upon the traversing left S1 nerve root at this level.
Bilateral far lateral disc bulges are noted at the L3-L4, L4-L5 and L5-S1 levels. Facetal hypertrophy is seen at the L3-L4 and L4-L5 levels.
There is a mild posterior disc bulge at the L4-L5 level.
An osteophyte is seen to arise from the postero-inferior aspect of the L5 vertebral body.
The rest of the lumbar intervertebral discs show mild loss of water content. A focal area of hyperintensity on the T1 Weighted images within the L3 vertebral body may represent a hemangioma with high fat content.
The rest of the lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints and 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 S2 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
13.0 mm at L3-L4
12.0 mm at L4-L5
8.0 mm at L5-S1.
1. Retroplacement of the L5 vertebra over the S1 vertebra.
2. Large postero-central and left postero-lateral disc herniations with a tight canal and indentation upon the traversing left S1 nerve root at this level.
3. Facetal hypertrophy at the L3-L4 and L4-L5 levels.