sb/hs/nl/rg.
Date : 00.00.00
Name of the Patient : Abc XyzHamed lmn / F / 40 yrs.
Referred by : Dr. Abc Xyzoshipura.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE since December 0000.
EXAMINATION :
M.R.I of the lumbo-sacro-coccygeal region was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted sagittal images.
3 mm thick T1 Weighted sagittal images.
5 mm thick T1 Weighted and T2 Weighted axial images.
6 mm thick T1 Weighted axial images.
OBSERVATION :
There is loss of water content of the L4-L5 intervertebral disc.
A small, postero-central disc herniation is seen at the L5-S1 level.
A posterior disc bulge with peridiscal osteophytes is noted at the L4-L5 level.
A minimal posterior disc bulge is seen at the L3-L4 level.
Slight facetal hypertrophy is noted at the L5-S1 level bilaterally. The sacro-coccygeal region is unremarkable. The coccygeal vertebrae show normal signal intensity.
Scan-00002
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 L2 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 :
16.0 mm at L1-L2
14.0 mm at L2-L3
13.0 mm at L3-L4
12.0 mm at L4-L5
11.0 mm at L5-S1.
IMPRESSION :
The MRI features are suggestive of :
1. A small, postero-central disc herniation at the L5-S1 level.
2. A posterior disc bulge with peridiscal osteophytes at the L4-L5 level.
3. Slight facetal hypertrophy at the L5-S1 level.