Date : 00.00.00
Name of the Patient : Abc Xyz lmn / M / 25 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE 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 appears to be sacralization of the L5 vertebra and it is as marked on the film. Please correlate with plain radiographs.
There is a large posterior disc herniation at the L2-L3 level with peridiscal osteophytes and anterior indentation of the thecal sac. There is slight superior migration of the disc which is seen to lie posterior to the L2 vertebral body. This disc shows loss of water content.
A posterior disc bulge with peridiscal osteophytes is seen at the D11-D12 level. Also seen is a posterior disc bulge at the L4-L5 level.
Schmorls nodes are noted in the dorso-lumbar region.
The L4-L5 and L5-S1 facet joints show mild degenerative changes.
Type II degenerative changes are seen in the L2 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 D12-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 :
15.0 mm at L1-L2
8.0 mm at L2-L3
12.0 mm at L3-L4
10.0 mm at L4-L5
12.0 mm at L5-S1.
The MRI features are suggestive of :
1. A large posterior disc herniation at the L2-L3 level with peridiscal osteophytes with slight superior migration of the disc. A tight canal is seen at the L2-L3 level.
2. Probable sacralization of the L5 vertebra. Please correlate with plain radiographs.