Date : 00.00.00
Name of the Patient : Abc Xyz Bhlmn / M / 28 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE with paresthesias since 3 months.
Alleged H/O vehicular accident 3 months ago.
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 L5-S1 intervertebral disc.
There is a postero-central and left postero-lateral disc herniation at the L5-S1 level with slight left neural foraminal narrowing. Slight inferior migration of the disc fragment is noted.
Minimal disc bulges are noted at the L3-L4 and L4-L5 levels.
Probable old fracture of the tip of the L2 spinous process is noted, with fatty change.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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.
- 2 - Scan-00005
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
17.0 mm at L1-L2
18.0 mm at L2-L3
17.0 mm at L3-L4
12.0 mm at L4-L5
12.0 mm at L5-S1.
1. Degenerated L5-S1 intervertebral disc with a postero-central and left postero-lateral disc herniation at the L5-S1 level.
2. Probable old fracture of the tip of the L2 spinous process (kindly correlate with plain radiographs).