ke/sb/nl/nl
Date : 00.00.00
Name of the Patient : Abc Xyz lmn / M / 28 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (left more than right) with paresthesias since January 0000.
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 scoliosis of the lumbar spine with convexity to the left.
There is a left paracentral disc herniation at the L5-S1 level with indentation upon the left S1 nerve root. There is inferior migration of the disc portion posterior to the S1 vertebral body.
A small posterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac. The L4-L5 and L5-S1 intervertebral discs show loss of water content.
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-S2 level.
Scan-00000
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
19.0 mm at L1-L2
18.0 mm at L2-L3
18.0 mm at L3-L4
13.0 mm at L4-L5
8.0 mm at L5-S1.
IMPRESSION :
1. Scoliosis of the lumbar spine with convexity to the left.
2. A left paracentral disc herniation at the L5-S1 level with indentation upon the left S1 nerve root. There is inferior migration of the disc portion posterior to the S1 vertebral body.
3. A small posterior disc herniation at the L4-L5 level.
As compared to the previous MRI dated 00.00.00, there is increase in the degree of the L5-S1 disc herniation.