sb/ke/nl/rg.
s Date : 00.00.00

Name of the Patient : Abc XyzG. Khalmn / M / 34 yrs.
Referred by : Dr. Abc Xyzawkar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with paresthesias since 2 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 L3-L4, L4-L5 and L5-S1 intervertebral discs.

There is a postero-central disc herniation with peridiscal osteophyte at the L5-S1 level indenting the dural theca anteriorly.

A fairly large, posteriorly extruded disc with a peridiscal osteophyte is noted at the L4-L5 level with thecal sac compression and bilateral neural foraminal narrowing. There is inferior migration of the disc fragment with indentation on the traversing L5 nerve roots bilaterally. There is also slight facetal and ligamentum flavum hypertrophy with resultant canal stenosis at the L4-L5 level.

A small, left paracentral disc herniation with peridiscal osteophyte is noted at the L3-L4 level with slight left neural foraminal narrowing.



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-L2 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 :

17.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
10.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

1. A postero-central disc herniation with peridiscal osteophyte at the L5-S1 level.

2. A fairly large, posteriorly extruded disc with a peridiscal osteophyte at the L4-L5 level with bilateral neural foraminal narrowing. There is inferior migration of the disc fragment with indentation on the traversing L5 nerve roots bilaterally. There is also slight facetal and ligamentum flavum hypertrophy with resultant canal stenosis at the L4-L5 level.

3. A small, left paracentral disc herniation with peridiscal osteophyte at the L3-L4 level.