ke.hs/nl/rg.
Date : 00.00.00

Name of the Patient : Abc XyzPlmn / M / 53 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the LLE and occasionally in the RLE.
Alleged H/O fall 1 month back.

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 L4-L5 level with anterior compression of the thecal sac and resultant canal stenosis. Posterior peridiscal osteophytes are also noted at this level.

Small postero-central disc herniations are noted at the L3-L4 and L5-S1 levels with anterior indentation of the thecal sac. A posterior disc bulge is noted at the L2-L3 level.

The L2-L3, L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content.

Mild facetal hypertrophy is noted at the L4-L5 and L5-S1 levels.

The lumbar vertebral bodies reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
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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 :

15.0 mm at L1-L2
13.0 mm at L2-L3
14.0 mm at L3-L4
7.0 mm at L4-L5
12.0 mm at L5-S1.

IMPRESSION :

1. A large postero-central disc herniation with posterior peridiscal osteophytes at the L4-L5 level with resultant canal stenosis.

2. Small postero-central disc herniations at the L3-L4 and L5-S1 levels.

3. A posterior disc bulge at the L2-L3 level.

4. Facetal hypertrophy at the L4-L5 and L5-S1 levels.