Date : 00.00.00
Name of the Patient : Abc XyzDlmn / M / 29 yrs.
Referred by : Dr. Abc Xyzhari.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE.
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 slight retroplacement of the L5 vertebra over the S1 vertebra.
A postero-central disc herniation is seen at the L5-S1 level with indentation upon the traversing left S1 nerve root. This disc shows loss of water content.
The L4-L5 and L5-S1 facet joints show mild degenerative changes.
There is a posterior disc bulge at the L4-L5 level.
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 S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
17.0 mm at L1-L2
17.0 mm at L2-L3
15.0 mm at L3-L4
13.0 mm at L4-L5
12.0 mm at L5-S1.
The MRI features are suggestive of :
1. Slight retroplacement of the L5 vertebra over the S1 vertebra.
2. A postero-central disc herniation at the L5-S1 level with indentation upon the traversing left S1 nerve root.
2. Mild facetal arthropathy at the L4-L5 and L5-S1 levels.