hs/sb/rg/nl
Date : 00.00.00
Name of the Patient : Abc XyzVarlmn / M / 19 yrs.
Referred by : Dr. Abc Xyzhari.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with tingling since 9 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 :
The L5-S1 intervertebral disc shows mild loss of water content.
A postero-central disc protusion with peridiscal osteophtyes is seen at the L5-S1 level with mild indentation upon the traversing S1 nerve roots bilaterally.
Small left postero-lateral and left far lateral disc herniations are seen at the L5-S1 level. There is mild left neural foraminal narrowing at this level.
A posterior disc bulge is seen to indent the thecal sac at the L4-L5 level.
The L5-S1 facet joints show mild degenerative changes.
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 D12-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
15.0 mm at L2-L3
15.0 mm at L3-L4
14.0 mm at L4-L5
10.0 mm at L5-S1.
IMPRESSION :
The MRI features are suggestive of :
1. A postero-central disc protusion with peridiscal osteophytes at the L5-S1 level with mild indentation upon the traversing S1 nerve roots bilaterally.
2. Small left postero-lateral and left far lateral disc herniations at the L5-S1 level.
3. A posterior disc bulge at the L4-L5 level.
4. Mild facetal arthropathy at the L5-S1 level.