sb/hs/rg/nl
Date : 00.00.00

Name of the Patient : Abc XyzMlmn / M / 53 yrs.
Referred by : Dr. Abc Xyzrade / Dr. Abc Xyzrankar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE since 3 months with paresthesias.
Alleged H/O fall on 00.00.00.

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 L4-L5 intervertebral discs.

There is a postero-central protruded disc at the L5-S1 level. The right L5-S1 facet joint shows degenerative changes.

There is a small posterior disc herniation at the L4-L5 level with bilateral neural foraminal narrowing. Slight facetal and ligamentum flavum hypertrophy is noted at this level. Bilateral far lateral (extraforaminal) disc bulges are noted at this level.

A small posterior disc bulge with peridiscal osteophytes 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-L2 level and the thecal sac terminates at the S1-S2 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
13.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. A small posterior disc herniation at the L4-L5 level with slight facetal and ligamentum flavum hypertrophy with a tight canal at this level.

2. A small posterior disc bulge with peridiscal osteophytes at the L3-L4 level.

3. Facetal arthropathy on the right side at the L5-S1 level.