bv/hs/nl/nl
Date : 00.00.00

Name of the Patient : Abc XyzMontlmn / M / 35 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 BLE (right more than left) with paresthesias in BUE and RLE.

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 and L5-S1 intervertebral discs with reduction in height of the L3-L4 disc.

There is a small postero-central and a right postero-lateral (foraminal) disc herniation with peridiscal osteophytes at the L5-S1 level with indentation upon the traversing S1 nerve roots (right more than left) and right neural foraminal narrowing.

There is a postero-central disc herniation with small peridiscal osteophytes at the L3-L4 level with ventral indentation of the thecal sac.

A small posterior disc bulge is seen at the L4-L5 level.

The facets at the L3-L4 and L4-L5 levels show hypertrophic changes. Degeneration is seen of the L5-S1 facet joints bilaterally.



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-S2 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
17.0 mm at L2-L3
11.0 mm at L3-L4
15.0 mm at L4-L5
14.0 mm at L5-S1.

IMPRESSION :

1. A postero-central disc herniation with small peridiscal osteophytes at the L3-L4 level.

2. A small postero-central and a right postero-lateral (foraminal) disc herniation with peridiscal osteophytes at the L5-S1 level with indentation upon the traversing S1 nerve roots (right more than left).

3. Facetal hypertrophy at the L3-L4 and L4-L5 levels and facetal arthropathy at the L5-S1 level.

As compared to the previous MRI dated 00.00.00, there is no significant change.