Name of the Patient : Abc Xyz Dlmn / M / 45 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O low back 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 is minimal scoliosis of the lumbar spine with convexity to the left.
The L5 vertebral body is marked on the film. There is loss of water content of the L5-S1 disc.
There is a posterior and left paracentral disc herniation with peridiscal osteophyte at the L5-S1 level with indentation on the traversing S1 nerve roots bilaterally, more on the left side. There is right neural foraminal narrowing at this level. Slight facetal hypertrophy is also noted.
A minimal posterior disc bulge is noted at the L4-L5 level with slight facetal hypertrophy at this level.
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 L2 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 :
18.0 mm at L1-L2
18.0 mm at L2-L3
18.0 mm at L3-L4
15.0 mm at L4-L5
12.0 mm at L5-S1.
1. A posterior and left paracentral disc herniation with peridiscal osteophyte at the L5-S1 level, indenting the traversing S1 nerve roots bilaterally, more on the left side. Facetal hypertrophy is also noted.
2. Slight facetal hypertrophy at the L4-L5 level.