sb/bv/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xylmn / M / 50 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias in the LLE since 3 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 the L4-L5 and L5-S1 intervertebral discs.

There is a left postero-lateral disc herniation at the L5-S1 level with left neural foraminal narrowing. A sequestered disc fragment is noted in the left lateral recess of S1, indenting the traversing left S1 nerve root. Slight superior migration of the sequestered disc fragment is also noted.

A small, posterior disc herniation is noted at the L4-L5 level with left neural foraminal narrowing and indentation on the extraforaminal segment of the left L4 nerve root.

Small posterior peridiscal osteophytes are seen at the L4-L5 and L5-S1 levels.

Slight hypertrophy of the facet joints is noted at the L4-L5 and L5-S1 levels.



Anterior peridiscal osteophytes are seen in the lower dorsal and lumbar regions .

A probable conjoint L5 and S1 nerve root sleeve is identified on the left side.

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 :

16.0 mm at L1-L2
17.0 mm at L2-L3
17.0 mm at L3-L4
14.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

1. A left postero-lateral disc herniation at the L5-S1 level with a sequestered disc fragment in the left lateral recess of S1, indenting the traversing left S1 nerve root and slight superior migration of the sequestered disc fragment.

2. A small, posterior disc herniation at the L4-L5 level with left neural foraminal narrowing and indentation on the extraforaminal segment of the left L4 nerve root.

3. Slight hypertrophy of the facet joints at the L4-L5 and L5-S1 levels.