sb/ke/nl/rg.
Date : 00.00.00

Name of the Patient : Abc XyzJasalmn / M / 47 yrs.
Referred by : Dr. Abc Xyzlkaka.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache since mid July 0000.
C/O radicular pain to the LLE with paresthesias since May 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 loss of water content of the L2-L3 and L4-L5 intervertebral discs.

There is sacralization of the L5 vertebra and the L1 vertebral body is as marked on the film.

There is a fairly large, left paracentral and left postero-lateral disc herniation with peridiscal osteophyte at the L4-L5 level with left neural foraminal narrowing and indentation on the traversing left L5 nerve root. The left L4 nerve root is impinged in the left neural foramen at the L4-L5 level. There is also facetal hypertrophy at this level.

A postero-central and left postero-lateral disc herniation is noted at the L3-L4 level with left neural foraminal narrowing.

Small postero-central protruded discs are noted at the L1-L2 and L2-L3 levels.
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The facet joints at the L2-L3 and L3-L4 levels appear slightly hypertrophied.

The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 :

16.0 mm at L1-L2
15.0 mm at L2-L3
15.0 mm at L3-L4
12.0 mm at L4-L5
11.0 mm at L5-S1.

Screening, T2 Weighted sagittal images of the dorsal spine reveal a small, postero-central protruded disc at the D10-D11 level.

IMPRESSION :

1. Sacralization of the L5 vertebra.

2. A fairly large, left paracentral and left postero-lateral disc herniation with peridiscal osteophyte at the L4-L5 level with left neural foraminal narrowing and indentation on the traversing left L5 nerve root. The left L4 nerve root is impinged in the left neural foramen at the L4-L5 level.

3. A postero-central and left postero-lateral disc herniation at the L3-L4 level.

4. Small postero-central protruded discs at the L1-L2 and L2-L3 levels.

5. Slight hypertrophy of the facet joints at the L2-L3 and L3-L4 levels.