sb/ke
Date : 00.00.00

Name of the Patient : Abc XyzPlmn / M / 70 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE 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 reduction in height of the L4-L5 intervertebral disc with loss of water content of the lumbar intervertebral discs.

A small postero-central protruded disc is noted at the L5-S1 level.

A posteriorly herniated disc with peridiscal osteophytes is noted at the L4-L5 level with bilateral neural foramial narrowing. A sequestered disc fragment is noted in the left lateral epidural space at the L5 indenting the traversing left L5 nerve root. Ligamentum flavum hypertrophy is noted at the L4 level.

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

The rest of the lumbar vertebral bodies reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
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The conus medullaris terminates at the L1-L2 level and the thecal sac terminates at the S1 level.

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

16.0 mm at L1-L2

17.0 mm at L2-L3

15.0 mm at L3-L4

9.0 mm at L4-L5

14.0 mm at L5-S1.

IMPRESSION :

1. A small postero-central protruded disc at the L5-S1 level.

2. A posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level with a sequestered disc fragment in the left lateral epidural space at the L5 indenting the traversing left L5 nerve root.