sb/hs/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyz Khailmn / M / 25 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 4 months.
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 loss of water content of the L4-L5 intervertebral disc.
There is a small right paracentral disc herniation at the L4-L5 level indenting the dural theca anteriorly.
A probable right sided conjoint nerve root is noted at the L5-S1 level and on the left side at the L5 level.
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 L2 level and the thecal sac terminates at the S2 level.
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The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
17.0 mm at L1-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
13.0 mm at L4-L5
15.0 mm at L5-S1.
IMPRESSION :
Degenerated L4-L5 intervertebral disc with a small right paracentral disc herniation at that level.