ke/sb/rg.
s Date : 00.00.00
Name of the Patient : Abc Xyzdin Mlmn / M / 50 yrs.
Referred by : Dr. Abc Xyzhah / Dr. Abc Xyzwadwala.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE since 20-22 days.
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 a large postero-central disc herniation at the L3-L4 level with compression of the thecal sac with a tight canal.
A left postero-lateral disc bulge is seen at the L4-L5 level with left neural foraminal narrowing. The L4-L5 facet joint on the left shows mild degenerative changes with slight hypertrophy of the ligamentum flavum on the left.
A small posterior disc bulge is noted at the L5-S1 level and postero-central disc protrusion at the L2-L3 level. The L2-L3, L3-L4 and L4-L5 intervertebral discs show slight loss of water content.
Fat is noted within the filum terminale at the L2 and L3 levels.
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.
- 2 - scan-00000
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 :
12.0 mm at L1-L2
10.0 mm at L2-L3
9.0 mm at L3-L4
12.0 mm at L4-L5
13.0 mm at L5-S1.
IMPRESSION :
1. A large postero-central disc herniation at the L3-L4 level with canal stenosis.
2. A left postero-lateral disc bulge at the L4-L5 level with facetal arthropathy on the left side at this level.
3. A small posterior disc bulge at the L5-S1 level.
4. A postero-central disc protrusion at the L2-L3 level.