Date : 00.00.00
Name of the Patient : Abc Xyz Llmn / M / 47 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE 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.
The L2-L3, L4-L5 and L5-S1 intervertebral discs show loss of water content and the L4-L5 intervertebral disc is decreased in height.
A large postero-central disc extrusion with small peridiscal osteophytes is seen to indent the thecal sac at the L4-L5 level. Mild facetal hypertrophy is seen at this level.
A left far lateral (extraforaminal) disc bulge is noted at the L2-L3 level with small posterior peridiscal osteophytes.
There is a postero-central disc protrusion at the L5-S1 level.
Type II degenerative changes are seen within the superior aspect of the L5 vertebral body.
The rest of 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.
- 2 - Scan-00007
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 :
18.0 mm at L1-L2
17.0 mm at L2-L3
17.0 mm at L3-L4
10.0 mm at L4-L5
11.0 mm at L5-S1.
The MRI features are suggestive of a large postero-central disc extrusion with small peridiscal osteophytes with a resultant tight canal at the L4-L5 level.
As compared to the previous MRI dated 00.00.00, there is an increase in the size of the disc extrusion at the L4-L5 level.