ke/hs/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Otlmn / F / 32 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE (left more than right) with paresthesias.

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 scoliosis of the lumbar spine with convexity to the right.

There is slight retroplacement of the L4 over the L5 and L5 over the S1 vertebrae.

A right paracentral and postero-lateral disc herniation is noted at the L4-L5 level with right neural foraminal narrowing.

A postero-central disc herniation, more to the left of the midline is noted at the L5-S1 level with mild indentation upon the traversing left S1 nerve root.

A right far lateral (extraforaminal) disc protrusion is seen to indent the extraforaminal portion of the exiting right L4 nerve root at the L4-L5 level.

The L4-L5 and L5-S1 facet joints show degenerative changes.

Small posterior peridiscal osteophytes are seen at the L4-L5 and L5-S1 levels. The L4-L5 and L5-S1 intervertebral discs show loss of water content.

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 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
16.0 mm at L2-L3
15.0 mm at L3-L4
11.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. Slight retroplacement of the L4 over the L5 and L5 over the S1 vertebrae.

2. A right paracentral and a postero-lateral disc herniation at the L4-L5 level.

3. A postero-central disc herniation, more to the left of the midline at the L5-S1 level with mild indentation upon the traversing left S1 nerve root.

4. A right far lateral (extraforaminal) disc protrusion indenting the extraforaminal portion of the exiting right L4 nerve root at the L4-L5 level.

5. Facetal arthropathy at the L4-L5 and L5-S1 levels.