ke/hs/nl/rg.
Date : 00.00.00
Name of the Patient : Abc Xyzt Bhojlmn / M / 20 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE since 8 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 :
The L5 vertebra is as marked on the film. Please correlate with plain radiographs.
There is a large postero-central disc extrusion at the L5-S1 level with slight inferior migration of the disc. There is resultant indentation upon the traversing right S1 nerve root. Posterior peridiscal osteophytes are also noted at this level. This disc shows loss of water content.
Small posterior disc bulges are noted at the L3-L4 and L4-L5 levels. Small posterior peridiscal osteophytes are seen at the L4-L5 level.
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 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 :
13.0 mm at L1-L2
14.0 mm at L2-L3
15.0 mm at L3-L4
14.0 mm at L4-L5
8.0 mm at L5-S1.
IMPRESSION :
The MRI features are suggestive of :
1. A large postero-central disc extrusion with posterior peridiscal osteophytes at the L5-S1 level with slight inferior migration of the disc and indentation upon the traversing right S1 nerve root.
2. Small posterior disc bulges at the L3-L4 and L4-L5 levels.