sb/ke/rg.
Date : 00.00.00

Name of the Patient : Abc XyzDlmn / M / 52 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain in the RLE with numbness since 00.00.00.

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 except the L1-L2 disc.

A postero-central disc herniation with peridiscal osteophytes is noted at the L3-L4 level indenting the dural theca anteriorly. A disc portion is seen to migrate inferiorly in the right lateral recess of the L4 vertebra with impingement of the right L4 nerve root.

There is a posteriorly herniated disc with peridiscal osteophytes at the L5-S1 level, with bilateral neural foraminal narrowing. Minimal indentation on the traversing right S1 nerve root is noted.

A small posterior disc bulge with peridiscal osteophytes is noted at the L4-L5 level with slight right neural foraminal narrowing.

A fairly large, right paracentral extruded disc is noted at the L2-L3 level with right neural foraminal narrowing and indentation on the traversing right L3 nerve root.

Facetal hypertrophy is noted at the L3-L4, L4-L5 and L5-S1 levels.
..2/.




The lumbar vertebral bodies reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12-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 :

20.0 mm at L1-L2
13.0 mm at L2-L3
13.0 mm at L3-L4
13.0 mm at L4-L5
12.0 mm at L5-S1.

IMPRESSION :

1. A posteriorly herniated disc with peridiscal osteophytes at the L5-S1 level, with minimal indentation on the traversing right S1 nerve root.

2. A small posterior disc bulge with peridiscal osteophytes at the L4-L5 level.

3. A postero-central disc herniation with peridiscal osteophytes at the L3-L4 level with a disc portion in the right lateral recess of the L4 vertebra with impingement of the right L4 nerve root.

4. A fairly large, right paracentral extruded disc at the L2-L3 level with indentation on the traversing right L3 nerve root.

5. Facetal hypertrophy at the L3-L4, L4-L5 and L5-S1 levels.