Date : 00.00.00
Name of the Patient : Abc Xyz Kelmn / F / 30 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 since 2 years.
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 sacralization of the L5 vertebral body and the L2 vertebra is as marked on the film.
A posterior disc herniation with peridiscal osteophytes is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. This disc shows loss of water content. The facet joints at this level appear hypertrophied with resultant tight lumbar canal.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of 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 :
14.0 mm at L1-L2
15.0 mm at L2-L3
14.0 mm at L3-L4
7.0 mm at L4-L5
8.0 mm at L5-S1.
The sacro-iliac joints were screened with 6 mm thick T1 Weighted coronal images which show hypointense areas in the right iliac bone adjacent to the right S.I. Joint.
1. Sacralization of the L5 vertebral body.
2. A posterior disc herniation with peridiscal osteophytes at the L4-L5 level with facetal hypertrophy and resultant canal stenosis.