ke/sb/nl/nl
Date : 00.00.00
Name of the Patient : Abc Xyzaklmn / F / 20 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O pain in the LLE with numbness.
EXAMINATION :
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.
OBSERVATION :
There is a large postero-central disc extrusion with peridiscal osteophytes at the L4-L5 level with compression of the thecal sac and a tight canal. Inferior migration of the disc fragment is seen with impingement of the traversing left L5 nerve root in the left lateral recess of the L5 vertebral body.
Small posterior disc herniation with peridiscal osteophytes is noted at the L3-L4 level and a postero-central disc protrusion is noted at the L5-S1 level. The L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content.
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 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 :
19.0 mm at L1-L2
19.0 mm at L2-L3
15.0 mm at L3-L4
6.0 mm at L4-L5
8.0 mm at L5-S1.
IMPRESSION :
1. A large postero-central disc extrusion with peridiscal osteophytes at the L4-L5 level with a tight canal. Inferior migration of the disc fragment is seen with impingement of the traversing left L5 nerve root in the left lateral recess of the L5 vertebral body.
2. Small posterior disc herniation with peridiscal osteophytes at the L3-L4 level.
3. A postero-central disc protrusion at the L5-S1 level.