sb/hs/nl/nl
Date : 00.00.00
Name of the Patient : Abc Xyzl Palmn / M / 38 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O low back pain radiating to the RLE since 15 days.
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 L4-L5 intervertebral disc.
There is a fairly large postero-central and right paracentral extruded disc with peridiscal osteophytes at the L4-L5 level with thecal sac compression and indentation on the traversing L5 nerve roots bilaterally. Slight inferior migration of the disc fragment is noted. Mild facetal hypertrophy is noted at the L4-L5 level.
A small posterior disc bulge is noted at the L3-L4 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.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
17.0 mm at L1-L2
16.0 mm at L2-L3
14.0 mm at L3-L4
2.0 mm at L4-L5
13.0 mm at L5-S1.
IMPRESSION :
A fairly large, postero-central and right paracentral extruded disc with peridiscal osteophytes at the L4-L5 level indenting the traversing L5 nerve roots bilaterally with severe canal stenosis at this level.