sb/hs/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyz. Welmn / F / 21 yrs.
Referred by : Dr. Abc Xyztchha.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE since 10 days.
Alleged H/O fall prior to this.

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 appears to be sacralization of the L5 vertebra and the L3 vertebra is as marked on the film.

There is loss of water content of the L4-L5 intervertebral disc.

There is a fairly large postero-central and a left paracentral disc herniation at the L4-L5 level with slight inferior migration of the disc fragment indenting the traversing left L5 nerve root.

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

The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 S1 level.
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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
12.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebra and the L3 vertebral body is as marked on the film. Please correlate with plain radiographs.

2. Degenerated L4-L5 intervertebral disc with a fairly large postero-central and a left paracentral disc herniation at this level with slight inferior migration of the disc fragment indenting the traversing left L5 nerve root.