sb/ke/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyze Khamblmn / M / 44 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE (left more than right with numbness since May 0000.

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 sacralization of the L5 vertebra.

There is loss of water content of the L1-L2, L2-L3 and L4-L5 intervertebral discs.

There is a fairly large, postero-central and left postero-lateral disc herniation at the L4-L5 level with left neural foraminal narrowing. Inferior migration of the disc fragment is noted along the posterior margin of the L5 vertebra, slightly more to the right of the midline. A sequestered disc fragment is noted in the left lateral recess of L4 and in the left neural foramen at the L4-L5 level with resultant indentation on the traversing left L4 nerve root.

A small posterior disc bulge is noted at the L3-L4 level.

A small postero-central disc herniation is seen at the L2-L3 level.


A postero-central protruded disc is noted at the L1-L2 level.

Slight hypertrophy of the L4-L5 facet joints is seen, bilaterally.

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 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
17.0 mm at L2-L3
18.0 mm at L3-L4
12.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebra.

2. A fairly large, postero-central and left postero-lateral disc herniation at the L4-L5 level with inferior migration of the disc fragment along the posterior margin of the L5 vertebra, slightly more to the right of the midline. A sequestered disc fragment is noted in the left lateral recess of L4 and in the left neural foramen at the L4-L5 level with resultant indentation on the traversing left L4 nerve root.
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3. A small postero-central disc herniation at the L2-L3 level.

4. A postero-central protruded disc at the L1-L2 level.

5. Slight facetal hypertrophy at the L4-L5 level, bilaterally.