sb/hs/rg/nl
Date : 00.00.00
Name of the Patient : Abc XyzShikalmn / M / 26 yrs.
Referred by : Dr. Abc Xyzhah / Dr. Abc Xyzan.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache and paresthesias in BLE (right more than left).
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 and L5-S1 intervertebral discs and loss of normal lumbar lordosis.
There is a postero-central disc protrusion at the L5-S1 level.
A small posterior disc bulge is noted at the L4-L5 level. Bilateral far lateral (extraforaminal) disc bulges are seen at the L5-S1 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.
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 :
17.0 mm at L1-L2
14.0 mm at L2-L3
15.0 mm at L3-L4
13.0 mm at L4-L5
9.0 mm at L5-S1.
IMPRESSION :
Degenerated L3-L4 and L5-S1 intervertebral discs with a postero-central disc protrusion at the L5-S1 level and a small posterior disc bulge at the L4-L5 level.