sb/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzayan Ylmn / M / 35 yrs.
Referred by : Dr. Abc Xyzhiri.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O wasting of the LLE with difficulty in walking since 4 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 :

There is loss of normal lumbar lordosis and loss of water content of the L1-L2, L4-L5 and L5-S1 intervertebral discs.

There is a left postero-lateral disc herniation with small peridiscal osteophytes at the L5-S1 level with left neural foraminal narrowing and minimal indentation on the traversing left S1 nerve root.

A posterior and left postero-lateral disc herniation with peridiscal osteophytes is noted at the L4-L5 level with indentation on the traversing left L5 nerve root.

A minimal posterior disc bulge is noted at the L3-L4 level.

Facetal hypertrophy is noted in the lumbar region.

The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
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The conus medullaris terminates at the L1-L2 level and the thecal sac terminates at the S2 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
13.0 mm at L3-L4
13.0 mm at L4-L5
13.0 mm at L5-S1.

The T2 Weighted sagittal images of the dorsal spine reveals facetal hypertrophy at the D1-D2 level.

IMPRESSION :

1. A left postero-lateral disc herniation with small peridiscal osteophytes at the L5-S1 level with left neural foraminal narrowing and minimal indentation on the traversing left S1 nerve root.

2. A posterior and left postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with indentation on the traversing left L5 nerve root.

3. Facetal hypertrophy in the lumbar region and at the D1-D2 level.