ke/sb/nl/nl
Date : 00.00.00
Name of the Patient : Abc Xyz Jalmn / M / 48 yrs.
Referred by : Dr. Abc Xyzmani.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
H/O fall from a bus and slipped twice within past 6 months.
C/O backache radiating to BLE (right more than left) since then.
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 right paracentral disc herniation with peridiscal osteophyte at the L3-L4 level with antero-lateral indentation of the thecal sac.
Postero-central disc herniations are noted at the L4-L5 and L5-S1 levels. 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 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
14.0 mm at L4-L5
10.0 mm at L5-S1.
IMPRESSION :
1. A right paracentral disc herniation with peridiscal osteophyte at the L3-L4 level.
2. Postero-central disc herniations at the L4-L5 and L5-S1 levels.