sb/hs/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyza Plmn / F / 35 yrs.
Referred by : Dr. Abc Xyzn.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O low back pain with pain radiating to RLE since 1 month with 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 lower lumbar intervertebral discs.

A small, postero-central and right postero-lateral disc herniation is noted at the L5-S1 level, with right neural foraminal narrowing. A small right far lateral (extraforaminal) disc herniation is seen to indent the extraforaminal portion of the exiting right L5 nerve root.

A fairly large, right paracentral disc extrusion is noted at the L4-L5 level with thecal sac compression and inferior migration of the disc fragment indenting the traversing right L5 nerve root.

Small posterior peridiscal osteophytes are noted at the L3-L4 level.

A small postero-central protruded disc with peridiscal osteophytes is noted at the L2-L3 level.

The L5-S1 facet joints bilaterally and the left L4-L5 facet joint show degenerative changes.

Type II degenerative marrow changes are noted adjacent to the L4-L5 disc.

The rest of 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 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 :

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

IMPRESSION :

1. A fairly large, right paracentral disc extrusion at the L4-L5 level with inferior migration of the disc fragment indenting the traversing right L5 nerve root.

2. A small, postero-central, right postero-lateral and right far lateral disc herniations at the L5-S1 level.

3. Small posterior peridiscal osteophytes at the L3-L4 level.

4. A small postero-central protruded disc with peridiscal osteophytes at the L2-L3 level.

5. Facetal arthropathy, bilaterally at the L5-S1 level and on the left side at the L4-L5 level.