sb/hs/nl/rg.
Date : 00.00.00
Name of the Patient : Abc XyzQurlmn / M / 58 yrs.
Referred by : Dr. Abc Xyzoonawalla.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O low back pain with radiation of pain to the LLE since 2 months.
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 all the lumbar intervertebral discs except the L2-L3 and L3-L4 discs.
There is a small postero-central disc herniation with peridiscal osteophytes at the L5-S1 level.
A small, posterior disc bulge is noted at the L4-L5 level. The articular facets at this level appear slightly hypertrophied.
The L1-L2 facet joints show mild degenerative changes.
The lumbar vertebral bodies 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
19.0 mm at L2-L3
17.0 mm at L3-L4
15.0 mm at L4-L5
14.0 mm at L5-S1.
IMPRESSION :
1. A small, postero-central disc herniation with peridiscal osteophytes at the L5-S1 level.
2. Small, posterior disc bulge at the L4-L5 level, with slight facetal hypertrophy at that level.