sb/bv
Date : 00.00.00

Name of the Patient : Abc Xyzh D. lmn / M / 41 yrs.
Referred by : Dr. Abc Xyzlkarni.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with paresthesias since 1 month.

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 L3-L4, L4-L5 and L5-S1 intervertebral discs.

There is a left postero-lateral and left far lateral disc herniation at the L5-S1 level with left neural foraminal narrowing. Resultant indentation on the traversing left S1 nerve root and indentation on the extraforaminal segment of the left L5 nerve root is noted.

There is a fairly large, right paracentral extruded disc at the L4-L5 level with right neural foraminal narrowing and indentation on the foraminal right L4 nerve root. A sequestered disc fragment is noted in the right lateral recess of L5 compressing the thecal sac with impingement of the right L5 nerve root.

A small posterior disc bulge with peridiscal osteophyte is noted at the L3-L4 level.

Slight facetal hypertrophy is noted at the L4-L5 and L5 levels with mild facet joint effusion on the right at the L4-L5 level.
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Type II degenerative marrow changes are noted adjacent to the L5-S1 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 D12 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 :

19.0 mm at L1-L2
18.0 mm at L2-L3
14.0 mm at L3-L4
7.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. A fairly large, right paracentral extruded disc at the L4-L5 level with right neural foraminal narrowing and indentation on the foraminal right L4 nerve root. A sequestered disc fragment is noted in the right lateral recess of L5 with impingement of the right L5 nerve root.

2. A left postero-lateral and left far lateral disc herniation at the L5-S1 level with indentation on the traversing left S1 nerve root and indentation on the extraforaminal segment of the left L5 nerve root at that level.

3. A small posterior disc bulge with peridiscal osteophyte at the L3-L4 level.

4. Slight facetal hypertrophy at the L4-L5 and L5 levels with mild facet joint effusion on the right at the L4-L5 level.