ke/sb/nl/rg.
Date : 00.00.00

Name of the Patient : Abc XyzDawood Sunlmn / M / 45 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain to the RLE with paresthesias since January 0000.

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 posterior disc herniation at the L4-L5 level with anterior indentation of the thecal sac. Slight inferior migration of the disc is seen with indentation upon the right L5 nerve root. Mild facetal arthropathy is noted at this level.

Minimal posterior disc bulge is noted at the L5-S1 level. 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
17.0 mm at L2-L3
16.0 mm at L3-L4
14.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

Degenerated L4-L5 and L5-S1 intervertebral discs with a posterior disc herniation at the L4-L5 level with slight inferior migration of the disc with indentation upon the right L5 nerve root.