Date : 00.00.00

Name of the Patient : Abc Xyz lmn / F / 35 yrs.
Referred by : Dr. Abc Xyzhah / Dr. Abc Xyzehta.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE since 20-22 days with ? bladder incontinence since 2 days.

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 and L5-S1 intervertebral discs.

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

There is a postero-central and left paracentral disc herniation with peridiscal osteophytes at the L4-L5 level with indentation on the traversing left L5 nerve root.

The lumbar vertebral bodies and the remaining intervertebral discs show normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The uterus is retroverted and shows a fibroid in the visualized myometrium. Further evaluation (e.g. with sonograpy).

The conus medullaris terminates at the D12-L1 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 :

18.0 mm at L1-L2

18.0 mm at L2-L3

16.0 mm at L3-L4

10.0 mm at L4-L5

9.0 mm at L5-S1.

IMPRESSION :

Degenerated L4-L5 and L5-S1 discs with :

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

2. A postero-central and left paracentral disc herniation with peridiscal osteophytes at the L4-L5 level.