Date : 00.00.00
Name of the Patient : Abc Xyz Slmn / M / 42 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with radiation of pain to the LLE.
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 :
The L1-L2 and L5-S1 intervertebral discs show loss of water content.
There is a postero-central disc extrusion with peridiscal osteophytes indenting the thecal sac at the L5-S1 level. Also seen is impingement of the traversing left S1 nerve root and indentation upon the traversing right S1 nerve root at this level.
A left postero-lateral (foraminal) disc herniation is seen to narrow the left neuralforamen and indent the exiting left L5 nerve root at the L5-S1 level. The left facet joint at this level shows mild degenerative changes.
A posterior disc bulge is noted at the L1-L2 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 L1 level and the thecal sac terminates at the S2 level.
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The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
16.0 mm at L1-L2
18.0 mm at L2-L3
17.0 mm at L3-L4
16.0 mm at L4-L5
12.0 mm at L5-S1.
The dorsal spine was screened with 5 mm thick T1 Weighted sagittal images and does not show any significant feature of note.
IMPRESSION :
The MRI features are suggestive of :
1. A postero-central disc extrusion with peridiscal osteophytes impinging
the traversing left S1 nerve root at the L5-S1 level.
2. A left postero-lateral (foraminal) disc herniation at the L5-S1 level.
3. Mild facetal arthropathy on the left side at the L5-S1 level.