a Date : 00.00.00
Name of the Patient : Abc Xyzoylmn / M / 30 yrs.
Referred by : Dr. Abc Xyzs.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
H/O accidental injury in October 0000 with quadriplegia. Treated with traction and improved partially.
C/O weakness of grip on the right side, walks with crutches, low back pain, gait imbalance, more to the left and buckling of knees since then.
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 D12-L1 and L4-L5 intervertebral disc.
A small, postero-central and right postero-lateral disc bulge with peridiscal osteophytes is noted at the L4-L5 level with slight right neural foraminal narrowing. A minimal posterior disc bulge is noted at the L3-L4 level.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
- 2 - Scan : 00009a
The conus medullaris terminates at the D12-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 :
18.0 mm at L1-L2
17.0 mm at L2-L3
14.0 mm at L3-L4
11.0 mm at L4-L5
13.0 mm at L5-S1.
IMPRESSION :
Degenerated L4-L5 disc with a small postero-central and right postero-lateral disc bulge with peridiscal osteophytes narrowing the right neural foramen at this level.