sb/bv/nl/rg.
Date : 00.00.00
Name of the Patient : Abc Xyz M. lmn / M / 36 yrs.
Referred by : Dr. Abc Xyzrnad.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 7 days.
Similar complaints earlier in 0000 and 0000. Recovered.
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 L4-L5 and L5-S1 intervertebral discs.
There is slight retroplacement of the L5 over the S1 vertebra.
Postero-central disc herniations are noted at the L4-L5 and L5-S1 levels with slight inferior migration of the disc at these levels. Ventral indentation on the thecal sac is noted over these levels.
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 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 :
19.0 mm at L1-L2
19.0 mm at L2-L3
17.0 mm at L3-L4
16.0 mm at L4-L5
14.0 mm at L5-S1.
IMPRESSION :
Degenerated L4-L5 and L5-S1 discs with postero-central disc herniations at these levels.