sb/bv/rg/nl
Name of the Patient : Abc XyzRalmn / M / 32 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 since 3-4 months.
H/O fall 2 months ago.
EXAMINATION :
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.
OBSERVATION :
There is loss of water content of the L4-L5 intervertebral disc.
There is a fairly large postero-central and left paracentral extruded disc at the L4-L5 level with slight inferior migration of the disc fragment indenting the thecal sac and traversing left L5 nerve root.
A left far lateral disc bulge is seen at the L5-S1 level indenting the left L5 nerve root.
Facetal hypertrophy is noted at the L5-S1 level bilaterally, more marked on the left side.
Focal fatty marrow change is noted along the antero-inferior margin of the L1 vertebral body. The rest of the visualized lumbar vertebral bodies show preponderance of red marrow compared to the normal fatty marrow.
>
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 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 :
17.0 mm at L1-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
7.0 mm at L4-L5
12.0 mm at L5-S1.
IMPRESSION :
1. A fairly large postero-central and left paracentral extruded disc at the L4-L5 level with slight inferior migration of the disc fragment indenting the thecal sac and traversing left L5 nerve root.
2. Facetal hypertrophy at the L5-S1 level bilaterally.