hs/sb/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzhammed lmn / M / 33 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE with paresthesias since 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 mild retroplacement of the L4 over the L5 and L5 over the S1 vertebrae.

There is a large postero-central disc extrusion with small peridiscal osteophytes, more to the left of the midline compressing upon the thecal sac at the L5-S1 level. A disc portion is seen to lie within the left lateral recess of the L5 and S1 vertebrae. Also seen is impingement of the traversing left S1 nerve root.

Left postero-lateral and left far lateral disc herniations are seen to narrow the left neural foramen and indent the extraforaminal portion of the exiting left L5 nerve root respectively at the L5-S1 level.

A posterior disc bulge is noted at the L4-L5 level.
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Facetal hypertrophy is seen at the L4-L5 and L5-S1 levels. The intervertebral discs at these levels show loss of water content.

Type II degenerative changes are noted in the S1 vertebral body adjacent to the L5-S1 intervertebral disc.

The rest of 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 S1 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

19.0 mm at L1-L2
19.0 mm at L2-L3
21.0 mm at L3-L4
18.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. A large postero-central disc extrusion with small peridiscal osteophytes, more to the left of the midline with canal stenosis at the L5-S1 level. A disc portion is seen to lie within the left lateral recess of the L5 and S1 vertebrae.

2. Left postero-lateral and left far lateral disc herniations indenting the extraforaminal portion of the exiting left L5 nerve root respectively at the L5-S1 level.

3. Facetal hypertrophy at the L4-L5 and L5-S1 levels.