sb/hs/nl/nl
Date : 00.00.00

Name of the Patient : Abc XyzVlmn / F / 40 yrs.
Referred by : Dr. Abc Xyzrani.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the LLE with numbness since 3 months.
Alleged H/O fall 3 months ago.

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 appears to be sacralization of the L5 vertebra, which is as marked on the film. Please correlate with plain radiographs.

There is a left paracentral disc herniation with peridiscal osteophytes at the L4-L5 level with slight inferior migration of the disc fragment into the left lateral recess of L5 and indentation on the traversing left L5 nerve root which is probably inflamed. A left far lateral (extraforaminal) disc bulge is also noted at this level.

A minimal posterior disc bulge is noted at the L3-L4 level.

The articular facets at the L3-L4 and L4-L5 levels appear slightly hypertrophied.






Focal fatty marrow changes are noted in the D12 and L1 vertebral bodies and along the superior margin of the L5 vertebral body. The L5-S1 intervertebral disc shows loss of water content.

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 :

16.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
13.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebra.

2. A left paracentral disc herniation with peridiscal osteophytes at the L4-L5 level with slight inferior migration of the disc fragment into the left lateral recess of L5 with indentation upon the traversing left L5 nerve root, which is probably inflamed.