Date : 00.00.00
Name of the Patient : Abc Xyzar D. Shlmn / M / 35 yrs.
Referred by : Dr. Abc Xyzapadia.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE with tingling.
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 loss of water content of the L4-L5 and L5-S1 intervertebral discs.
There is a fairly large, left paracentral extruded disc with peridiscal osteophytes at the L5-S1 level with indentation on the traversing left S1 nerve root. A sequestered disc fragment is noted along the posterior margin of the L5 vertebral body slightly to the right of the midline, indenting the traversing right S1 nerve root.
A postero-central protruded disc with small peridiscal osteophytes is noted at the L4-L5 level, indenting the dural theca anteriorly.
Slight facetal hypertrophy is noted at the L4-L5 and L5-S1 levels. Focal fatty marrow changes are noted in the L5 vertebral body.
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-L2 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
16.0 mm at L2-L3
17.0 mm at L3-L4
12.0 mm at L4-L5
6.0 mm at L5-S1.
1. A fairly large, left paracentral extruded disc with peridiscal osteophytes at the L5-S1 level with indentation on the traversing left S1 nerve root with a sequestered disc fragment along the posterior margin of the L5 vertebral body slightly to the right of the midline, indenting the traversing right S1 nerve root.
2. A small postero-central protruded disc with small peridiscal osteophytes at the L4-L5 level.
3. Slight facetal hypertrophy at the L4-L5 and L5-S1 levels.
27th December 0000
Dear Dr. Abc Xyzapadia,
The screening of the hip joints of Mr. Aliasgar D. Shakir, Male, aged 35 years (whose previous MRI Lumbo-sacral spine was done on 00.00.00) was done as requested, using 5 mm thick T1 Weighted coronal images. Altered signal is noted in the head of the left femur which most likely suggests avascular necrosis.
A dedicated study of both hip joints is, however, indicated.
Thanking you once again for your kind reference.