sb/bv/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyznt Blmn / M / 48 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE 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 loss of water content of the L3-L4 and L4-L5 intervertebral discs.
There is a fairly large, posteriorly herniated disc with a peridiscal osteophyte at the L4-L5 level with thecal sac compression and canal stenosis.
A small, postero-central and right paracentral disc herniation with peridiscal osteophytes is noted at the L3-L4 level indenting the dural theca anteriorly.
Minimal postero-central protruded discs are noted at the L5-S1 and L2-L3 levels. The right S1 nerve root appears to be of larger calibre ? baggy nerve root sleeve.
The facet joints at the L4-L5 and L3-L4 levels appear slightly hypertrophied.
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.
..2/.
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 :
18.0 mm at L1-L2
17.0 mm at L2-L3
13.0 mm at L3-L4
9.0 mm at L4-L5
12.0 mm at L5-S1.
IMPRESSION :
1. A fairly large, posteriorly herniated disc with a peridiscal osteophyte at the L4-L5 level with canal stenosis.
2. A small, postero-central and right paracentral disc herniation with peridiscal osteophytes at the L3-L4 level.
3. Slight facetal hypertrophy at the L3-L4 and L4-L5 levels.
As compared to the previous MRI dated 00.00.00, there is no significant change noted.