ke/bv/nl/rg.
Date : 00.00.00
Name of the Patient : Abc Xyz Plmn / F / 26 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE with tingling since February 0000.
Patient is on AKT since 00.00.00 for bone TB.
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 normal lumbar lordosis and loss of water content of the L5-S1 intervertebral disc.
There is right paracentral disc extrusion at the L5-S1 level with antero-lateral indentation of the thecal sac. There is inferior migration of the disc in the right lateral recess of the S1 vertebra and impingement of the right S1 nerve root.
The L3-L4, L4-L5 and L5-S1 facet joints show degenerative changes.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12 level and the thecal sac terminates at the S1 level.
..2/.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
13.0 mm at L1-L2
16.0 mm at L2-L3
14.0 mm at L3-L4
12.0 mm at L4-L5
10.0 mm at L5-S1.
Incidental note is made of bulky uterus.
IMPRESSION :
A right paracentral disc extrusion at the L5-S1 level with inferior migration of the disc in the right lateral recess of the S1 vertebra impinging the right S1 nerve root with canal stenosis.