sb/ke/nl/rg
Date : 00.00.00

Name of the Patient : Abc Xyz Slmn / M / 40 yrs.
Referred by : Dr. Abc Xyzlkarni.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias since 5 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 :

There is probable sacralization of the L5 vertebra and the L4 vertebral body is as marked on the film.

There is a fairly large, posteriorly extruded disc with peridiscal osteophyte at the L4-L5 level with thecal sac compression and indentation on the traversing L5 nerve roots bilaterally. A probable sequestered disc fragment is noted in the anterior epidural space at the L4-L5. There is loss of water content of the L4-L5 intervertebral disc.

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

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.
Scan-00002

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 :

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

IMPRESSION :

1. Probable sacralization of the L5 vertebra and the L4 vertebral body is as marked on the film.

2. A fairly large, posteriorly extruded disc with peridiscal osteophyte at the L4-L5 level with indentation on the traversing L5 nerve roots bilaterally. A probable sequestered disc fragment is noted in the anterior epidural space at the L4-L5 level.

3. Canal stenosis at the L4-L5 level.