Date : 00.00.00
Name of the Patient : Abc Xyzli Qalmn / M / 38 yrs.
Referred by : Dr. Abc Xyzatt.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE since 5 years.
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 loss of water content of the L4-L5 and L5-S1 intervertebral discs. These discs also appear reduced in height.
Small posterior disc protrusion with peridiscal osteophyte is noted at the L5-S1 level.
A left paracentral disc herniation is noted at the L4-L5 level with minimal indentation of the traversing left L5 nerve root. Posterior peridiscal osteophytes are also noted at this level. The facet joints at the L4-L5 level appears slightly hypertrophied.
Type II degenerative marrow changes are noted adjacent to the L5-S1 disc and Type I and Type II degenerative marrow changes are noted adjacent to the L4-L5 intervertebral disc.
The rest of the lumbar vertebral bodies show preponderance of hematopoeitic marrow. 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 S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
20.0 mm at L1-L2
19.0 mm at L2-L3
17.0 mm at L3-L4
15.0 mm at L4-L5
13.0 mm at L5-S1.
Incidentally noted is a focal hypointense signal in the iliac bone adjacent to the right sacro-iliac joint which is of ? etiology, ? bone island, ?? subchondral degeneration.
IMPRESSION :
1. Small posterior disc protrusion with peridiscal osteophyte at the L5-S1 level.
2. A left paracentral disc herniation at the L4-L5 level with minimal indentation of the traversing left L5 nerve root with slight facetal hypertrophy at this level.