hs/ke/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzsir Khamlmn / M / 44 yrs.
Referred by : Dr. Abc Xyzapadia.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE and paresthesias.

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 lumbar intervertebral discs.

There is a large right paracentral disc extrusion indenting the thecal sac and the traversing S1 nerve roots at the L5-S1 level. A small disc portion is seen to lie within the right lateral recess of the S1 vertebra with posterior displacement of the traversing right S1 nerve root. A small right postero-lateral disc herniation is seen to narrow the right neural foramen at the L5-S1 level.

Mild posterior disc bulge is noted at the L4-L5 level.

The L3-L4 facet joints show hypertrophic degenerative changes bilaterally.

Type II degenerative changes are noted within the L5 and S1 vertebral bodies adjacent to the L5-S1 disc.




The rest of the lumbar vertebral bodies reveal normal signal intensity. The remaining 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 S2 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

16.0 mm at L1-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
15.0 mm at L4-L5
12.0 mm at L5-S1.

IMPRESSION :

1. A large right paracentral disc extrusion indenting the traversing S1 nerve roots at the L5-S1 level. A small disc portion is seen to lie within the right lateral recess of the S1 vertebra with posterior displacement of the traversing right S1 nerve root.

2. A small right postero-lateral disc herniation at the L5-S1 level.

3. Hypertrophic facetal arthropathy at the L3-L4 level.