sb/ke/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz Chandravalmn / M / 38 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE since 1 1/2 months.

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 lumbar intervertebral discs.

There is scoliosis of the lumbar spine with convexity to the left. Minimal forward translation of the L5 over the S1 vertebra is noted.

There is a congenital anomaly of the L5 vertebra with an absent left pedicle of L5 and spina bifida at that level.

Right far lateral disc herniations are noted at the L4-L5 and L5-S1 levels indenting the extraforaminal segment of the right L4 and L5 nerve roots respectively.

Small left and right far lateral disc herniations are noted at the L3-L4 level indenting the extraforaminal segments of the left L3 nerve root.

The facet joints at the L4-L5 and L5-S1 levels appear slightly hypertrophied.

The lumbar vertebral bodies reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
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The conus medullaris terminates at the D12 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 :

14.0 mm at L1-L2
12.0 mm at L2-L3
11.0 mm at L3-L4
9.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. Slight forward translation of the L5 over the S1 vertebra.

2. Congenital anomaly of the L5 vertebra with an absent left pedicle of L5 and spina bifida at that level.

3. Right far lateral disc herniations at the L4-L5 and L5-S1 levels indenting the extraforaminal segments of the right L4 and L5 nerve roots respectively.

4. Small left and right far lateral disc herniations at the L3-L4 level indenting the extraforaminal segment of the left L3 nerve root.

5. Slight hypertrophy of the facet joints at the L4-L5 and L5-S1 levels.