hs/ke/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Malmn / M / 47 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache.

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 slight retroplacement of the L4 vertebra over the L5 vertebra. The L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content.

A right paracentral disc herniation is seen to indent and displace the traversing right S1 nerve root posteriorly at the L5-S1 level.

A large postero-central disc herniation is seen to indent the thecal sac at the L4-L5 level. A disc portion is seen to lie within the anterior epidural space at the L5 vertebral level. There is facetal hypertrophy at the L4-L5 level with probable joint effusion.

There is a posterior disc bulge at the L3-L4 level. Anterior disc herniations are seen at the L2-L3 and L3-L4 levels.





Facetal hypertrophy is noted at the L3-L4 and L5-S1 levels.

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 D12-L1 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 :

20.0 mm at L1-L2
19.0 mm at L2-L3
19.0 mm at L3-L4
14.0 mm at L4-L5
15.0 mm at L5-S1.

IMPRESSION :

1. A right paracentral disc herniation at the L5-S1 level.

2. A large postero-central disc herniation with canal stenosis at the L4-L5 level and a disc portion is seen to lie within the anterior epidural space at the L5 vertebral level.

3. Facetal hypertrophy at the L4-L5 and L5-S1 levels.