sb/ke
Date : 00.00.00

Name of the Patient : Abc Xyzed Yunus Shlmn / M / 55 yrs.
Referred by : Dr. Abc Xyzpadia.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE with paresthesias since many years.

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 normal lumbar lordosis and loss of water content of the lower dorsal and the L3-L4, L4-L5 and L5-S1 intervertebral discs.

There is a fairly large, left paracentral and left postero-lateral disc herniation at the L5-S1 level with left neural foraminal narrowing and indentation on the traversing left S1 nerve root. A posterior peridiscal osteophyte is also noted at this level.

A posteriorly herniated disc with a posterior peridiscal osteophyte is noted at the L4-L5 level slightly more to the right of the midline. Resultant thecal sac compression and minimal indentation on the traversing right L5 nerve root is noted.







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

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. Slight hypertrophy of the L4-L5 facet joints is noted. 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 S1 level.

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

15.0 mm at L1-L2
15.0 mm at L2-L3
13.0 mm at L3-L4
9.0 mm at L4-L5
13.0 mm at L5-S1.

IMPRESSION :

1. A fairly large, left paracentral and left postero-lateral disc herniation with peridiscal osteophyte at the L5-S1 level with left neural foraminal narrowing and indentation on the traversing left S1 nerve root.

2. A posteriorly herniated disc with a posterior peridiscal osteophyte at the L4-L5 level, slightly more to the right of the midline with minimal indentation on the traversing right L5 nerve root.

3. Slight facetal hypertrophy at the L4-L5 level with a tight canal at that level.