sb/hs/nl/rg.
Date : 00.00.00
Name of the Patient : Abc Xyzti lmn / M / 32 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating 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 :
There is loss of normal lumbar lordosis and loss of water content of the L4-L5 and L5-S1 intervertebral discs.
There is a postero-central disc herniation at the L5-S1 level.
There is a postero-central and right paracentral extruded disc at the L4-L5 level with right neural foraminal narrowing and indentation on the traversing right L5 nerve root. Slight inferior migration of the disc fragment is noted.
Type II degenerative marrow changes are noted in the S1 vertebral body adjacent to the L5-S1 disc.
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 D12-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
18.0 mm at L2-L3
17.0 mm at L3-L4
10.0 mm at L4-L5
12.0 mm at L5-S1.
IMPRESSION :
1. A postero-central disc herniation at the L5-S1 level.
2. A postero-central and right paracentral extruded disc at the L4-L5 level with indentation upon the traversing right L5 nerve root. Slight inferior migration of the disc fragment is noted.
3. Canal stenosis at the L4-L5 level.