Date : 00.00.00
Name of the Patient : Abc Xyz Colmn / M / 39 yrs.
Referred by : Dr. Abc Xyzcha.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE since 20-25 days.
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.
Few images show patient motion.
There is loss of normal lumbar lordosis. The L5-S1 intervertebral disc shows loss of water content and appears reduced in height.
There is a large right paracentral disc extrusion indenting the thecal sac and impinging the traversing right S1 nerve root at the L5-S1 level. A small disc portion is seen to lie within the right lateral recess of S1 vertebra. Small posterior peridiscal osteophytes are also seen at this level.
There is a posterior disc bulge at the L4-L5 level. Bilateral far lateral disc bulges are noted over the L2-L3 to the L5-S1 level.
The L5-S1 facet joints show mild degenerative changes.
Fat is noted within the thecal sac at the L5-S1 and S1 levels.
There is a probable conjoint nerve root sleeve on the right side at the L5 vertebral level.
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.
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 :
18.0 mm at L1-L2
18.0 mm at L2-L3
16.0 mm at L3-L4
15.0 mm at L4-L5
12.0 mm at L5-S1.
The MRI features are suggestive of a large right paracentral disc extrusion with small peridiscal osteophytes impinging the traversing right S1 nerve root at the L5-S1 level with mild facetal arthropathy at this level.