hs/sb/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyz. Dlmn / M / 56 yrs.
Referred by : Dr. Abc Xyzonawalla.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with radiation of pain to the RLE 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 :

A small right paracentral disc herniation is seen to indent the thecal sac at the L5-S1 level. Right postero-lateral and right far lateral disc herniations are seen to narrow the right neural foramen and indent the exiting right L5 nerve root at the L5-S1 level.

Left postero-lateral and left far lateral disc herniations are seen to narrow the left neural foramen and indent the exiting left L4 nerve root at the L4-L5 level. A right far lateral (extraforaminal) disc protrusion is noted at this level.

A right far lateral (extraforaminal) disc herniation is seen to indent the exiting right L3 nerve root at the L3-L4 level. The left facet joint at this level shows hypertrophic degenerative changes.

The L4-L5 and L5-S1 facet joints show degenerative changes with probable joint effusion at the L4-L5 level.


A posterior disc bulge is seen at the L4-L5 level.

The L3-L4, 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 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
16.0 mm at L2-L3
14.0 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 right paracentral disc herniation at the L5-S1 level.

2. Right postero-lateral and right far lateral disc herniations indenting the exiting right L5 nerve root at the L5-S1 level.

3. Left postero-lateral and left far lateral disc herniations indenting the exiting left L4 nerve root at the L4-L5 level.
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- 3 - Scan-00008




4. A right far lateral (extraforaminal) disc herniation
indenting the exiting right L3 nerve root at the L3-L4 level.

5. Hypertrophic facetal arthropathy on the left side at the L3-L4 level.

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

7. A right far lateral (extraforaminal) disc protrusion at the L4-L5 level.