sb/bv/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzlah Mohd.Hlmn / M / 44 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE with tingling since 4 years.

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 L3-L4 and L4-L5 intervertebral discs.

There is a small, postero-central protruded disc at the L5-S1 level with indentation upon the S1 nerve roots bilaterally.

There is a left paracentral and left postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with left neural foraminal narrowing and indentation on the traversing left L5 nerve root. Slight inferior migration of the disc fragment is noted into the left lateral recess of L5.

The right facet joint at the L5-S1 level and the facet joints at the L4-L5 level bilaterally appear slightly hypertrophied.



Anterior disc herniation with anterior peridiscal osteophytes is noted at the L3-L4 level. There is transepiphysial herniation of the L3-L4 disc through the antero-superior margin of the L4 vertebral body suggestive of a lumbar vertebra. Type III degenerative marrow changes are noted in the L4 vertebral body adjacent to the L3-L4 intervertebral disc.

The rest of 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 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
16.0 mm at L3-L4
13.0 mm at L4-L5
12.0 mm at L5-S1.

IMPRESSION :

1. A left paracentral and left postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with left neural foraminal narrowing, inferior migration of the disc and indentation on the traversing left L5 nerve root.

2. A small, postero-central protruded disc at the L5-S1 level.

3. Facetal hypertrophy on the right side at the L5-S1 level and at the L4-L5 level bilaterally.