Date : 00.00.00
Name of the Patient : Abc Xyzissa Anlmn / F / 65 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE and weakness with paresthesias.
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 partial sacralization of the L5 vertebra on the left side.
There is loss of water content of the lumbar intervertebral discs.
There is a postero-central and right paracentral disc herniation at the L3-L4 level with thecal sac compression, right neural foraminal narrowing and indentation on the traversing right L4 nerve root.
A postero-central disc herniation is noted at the L2-L3 level.
A small posterior disc bulge is noted at the L4-L5 level with slight right neural foraminal narrowing.
Slight facetal hypertrophy is noted at the L4-L5 and L5-S1 levels.
The lumbar vertebral bodies show spotty fatty marrow changes. Hemangioma is noted in the L3 vertebral body.
The remaining 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 :
15.0 mm at L1-L2
12.0 mm at L2-L3
12.0 mm at L3-L4
12.0 mm at L4-L5
10.0 mm at L5-S1.
1. Partial sacralization of the L5 vertebra on the left.
2. A postero-central and right paracentral disc herniation at the L3-L4 level with indentation on the traversing right L4 nerve root.
3. A postero-central disc herniation at the L2-L3 level.
4. A small posterior disc bulge at the L4-L5 level.
5. Slight facetal hypertrophy at the L4-L5 and L5-S1 levels.