ke/hs/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzed lmn / M / 28 yrs.
Referred by : Dr. Abc Xyztchha.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE 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 appears to be sacralization of the L5 vertebra and the L3 vertebra is as marked on the film. Please correlate with plain radiographs.

There is a large right paracentral and right postero-lateral disc extrusion at the L4-L5 level with right antero-lateral indentation of the thecal sac, right neural foraminal narrowing and indentation upon the traversing right L5 nerve root. There is superior migration of the disc into the right lateral recess of the L4 vertebra. Extruded disc material is also seen in the right neural foramen with impingement of the exiting right L4 nerve root. This disc shows loss of water content.

Type II degenerative changes are seen in the L4 and L5 vertebral bodies adjacent to the L4-L5 disc. The L4-L5 facet joints show mild degenerative changes.
Scan-00004


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 D12 level and the thecal sac terminates at the L5 level.

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

17.0 mm at L1-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
10.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebra. Please correlate with plain radiographs.

2. A large right paracentral and right postero-lateral disc extrusion at the L4-L5 level with indentation upon the traversing right L5 nerve root. There is superior migration of the disc into the right lateral recess of the L4 vertebra. Extruded disc material is also seen in the right neural foramen at the L4-L5 level with impingement of the exiting right L4 nerve root.