ke/bv/nl/nl
Date : 00.00.00
Name of the Patient : Abc Xyznnisha Shlmn / F / 40 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since 4 years which has increased since 1 month.
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 L3-L4 and L2-L3 intervertebral discs show slight loss of water content.
There is a right paracentral disc extrusion at the L4-L5 level with anterior indentation of the thecal sac and mild right neural foraminal narrowing. There is inferior migration of the disc portion which is seen to lie in the right lateral recess of the L5 vertebra and resultant impingement of the traversing right L5 nerve root. This disc appears dessicated (scans 102.4, 102.5, 103.4, 103.5, 105.2, 106.4 to 106.6).
Small posterior disc bulges are seen at the L2-L3 and L3-L4 levels. A small posterior disc herniation is noted at the D12-L1 level.
Type II degenerative changes are noted in the antero-superior portion of the L3 and L4 vertebral bodies.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12-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 :
17.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
13.0 mm at L4-L5
15.0 mm at L5-S1.
IMPRESSION :
A right paracentral disc extrusion at the L4-L5 level with inferior migration of the disc portion, lying in the right lateral recess of the L5 vertebra and resultant impingement of the traversing right L5 nerve root.