sb/ke/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyz. Glmn / F / 46 yrs.
Referred by : Dr. Abc Xyzoshipura.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O low back pain radiating to the RLE since December 0000 with paresthesias in the RLE since 15 days.

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 L3-L4, L4-L5 and L5-S1 intervertebral discs.

There is a fairly large, right paracentral and right postero-lateral disc herniation with peridiscal osteophyte at the L4-L5 level with right neural foraminal narrowing. Inferior migration of the disc fragment is noted into the right lateral recess of L5, impinging the right L5 nerve root. Slight facetal hypertrophy is also noted at the L4-L5 level.

A small, postero-central protruded disc is noted at the L5-S1 level. Slight left facetal hypertrophy is noted at this level.

A small, left postero-lateral protruded disc is noted at the L3-L4 level.






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 S2 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

20.0 mm at L1-L2
20.0 mm at L2-L3
19.0 mm at L3-L4
15.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. A fairly large, right paracentral and right postero-lateral disc herniation with peridiscal osteophyte at the L4-L5 level with inferior migration of the disc fragment into the right lateral recess of L5, impinging the right L5 nerve root.

2. A small, postero-central protruded disc at the L5-S1 level.

As compared to the previous MRI dated 00.00.00, scan no:0000, there is an increase in the degree of disc herniation at the L4-L5 level.