hs/ke/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyz Paranlmn / M / 48 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with radiation of pain to BLE (left more than right).
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 :
The L5 vertebra appears to be as marked on the film. Please correlate with plain radiographs.
A small left paracentral disc herniation with peridiscal osteophytes is seen at the L5-S1 level. Bilateral far lateral (extraforaminal) disc herniations are also seen at this level.
A posterior disc bulge is seen to indent the thecal sac at the L4-L5 level.
Facetal hypertrophy is noted at the L2-L3, L3-L4, L4-L5 and L5-S1 levels.
The L4-L5 and L5-S1 intervertebral discs show loss of water content.
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 :
18.0 mm at L1-L2
20.0 mm at L2-L3
20.0 mm at L3-L4
18.0 mm at L4-L5
14.0 mm at L5-S1.
IMPRESSION :
The MRI features are suggestive of :
1. A small left paracentral disc herniation with peridiscal osteophytes and bilateral far lateral (extraforaminal) disc herniatons at the L5-S1 level.
2. A posterior disc bulge at the L4-L5 level.
3. Facetal hypertrophy at the L2-L3, L3-L4, L4-L5 and L5-S1 levels.