sb/hs/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyzi Punalmn / M / 46 yrs.
Referred by : Dr. Abc Xyz.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE with paresthesias since 1 year.
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 and L5-S1 intervertebral discs.
A postero-central and left paracentral disc herniation with peridiscal osteophytes is noted at the L5-S1 level with slight inferior migration of the disc fragment indenting the traversing left S1 nerve root.
A posterior disc bulge is noted at the L4-L5 level with bilateral neural foraminal narrowing.
Slight hypertrophic degenerative changes of the facet joints are noted at the L4-L5 and L5-S1 levels.
A hemangioma with fat content is noted at the L2 vertebral body.
The rest of 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 :
17.0 mm at L1-L2
17.0 mm at L2-L3
15.0 mm at L3-L4
13.0 mm at L4-L5
11.0 mm at L5-S1.
IMPRESSION :
1. A postero-central and left paracentral disc herniation with peridiscal osteophytes at the L5-S1 level with slight inferior migration of the disc fragment indenting the traversing left S1 nerve root.
2. A small posterior disc bulge at the L4-L5 level with bilateral neural foraminal narrowing.
3. Slight hypertrophic facetal arthropathy at the L4-L5 and L5-S1 levels.