Date : 00.00.00
Name of the Patient : Abc Xyzhadur Ylmn / M / 45 yrs.
Referred by : Dr. Abc Xyzar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE with paresthesias in BLE (left more than right).
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 sacralization of the L5 vertebra which is as marked on the film.
There is slight retroplacement of the L4 over the L5 vertebra.
There is loss of water content of the L4-L5 and L5-S1 intervertebral discs and the L5-S1 disc appears reduced in height.
There is a fairly large, posteriorly extruded disc at the L4-L5 level with inferior migration of the disc fragment into the left lateral recess of L5, thecal sac compression and indentation on the traversing S1 nerve roots bilaterally.
A small posterior disc herniation is noted at the L3-L4 level with bilateral neural foraminal narrowing.
Facetal hypertrophy is noted in the lumbar region.
Fatty marrow changes are noted in the D12, L4 and L1 vertebral bodies.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12 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 :
15.0 mm at D12-L1
13.0 mm at L1-L2
13.0 mm at L2-L3
12.0 mm at L3-L4
7.0 mm at L4-L5
7.0 mm at L5-S1.
1. Sacralization of the L5 vertebra.
2. A fairly large, posteriorly extruded disc at the L4-L5 level with inferior migration of the disc fragment into the left lateral recess of L5 and indentation on the traversing S1 nerve roots bilaterally.
3. A small posterior disc herniation at the L3-L4 level with bilateral neural foraminal narrowing.
4. Facetal hypertrophy in the lumbar region.