sb/ke/nl/rg.
Date : 00.00.00

Name of the Patient : Abc XyzMolmn / M / 24 yrs.
Referred by : Dr. Abc XyzShah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O pain in the LLE with tingling since 6-7 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 loss of water content of the L4-L5 intervertebral disc.

There is a postero-central disc herniation with peridiscal osteophyte at the L4-L5 level with thecal sac compression. Inferior migration of the disc fragment is noted more to the left of the midline with resultant indentation on the traversing left L5 nerve root.

A small posterior disc bulge is noted at the L5-S1 level. Schmorls nodes are seen in the lower dorsal region.

Slight facetal hypertrophy is noted at the L4-L5 and L5-S1 levels, bilaterally and at the L2-L3 level on the left.

The pedicles of the L4 and L5 vertebrae appear congenitally short in the antero-posterior dimensions.
Scan-00002


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 :

15.0 mm at L1-L2
14.0 mm at L2-L3
11.0 mm at L3-L4
7.0 mm at L4-L5
7.0 mm at L5-S1.

IMPRESSION :

1. A postero-central disc herniation with peridiscal osteophyte at the L4-L5 level with inferior migration of the disc fragment, more to the left of the midline with resultant indentation on the traversing left L5 nerve root.

2. Slight facetal hypertrophy at the L4-L5 and L5-S1 levels, bilaterally and at the L2-L3 level on the left.

3. Congenitally short pedicles of the L4 and L5 vertebrae in the antero-posterior dimensions.