ke/sb/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzlmn / M / 30 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE with paresthesias since 1 year.

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 partial sacralization of the L5 vertebral body on the left side.

There is a large posterior disc extrusion at the L4-L5 level with severe compression of the thecal sac and canal stenosis. There is slight inferior migration of the disc with impingement of the L5 nerve roots.

Small postero-central disc herniations are noted at the L1-L2, L2-L3 and L3-L4 levels. The L2-L3 and L4-L5 intervertebral discs show loss of water content.

The L4-L5 facet joints show degenerative changes.

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 D12 level and the thecal sac terminates at the S2 level.
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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
14.0 mm at L3-L4
10.0 mm at L4-L5
14.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. Partial sacralization of the L5 vertebral body on the left side.

2. A large posterior disc extrusion at the L4-L5 level with slight inferior migration of the disc impinging the L5 nerve roots and canal stenosis at this level.

3. Small postero-central disc herniations at the L1-L2, L2-L3 and L3-L4 levels.

4. Facetal arthropathy at the L4-L5 level.