ke/hs
Date : 00.00.00

Name of the Patient : Abc XyzM. Jalmn / M / 40 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with numbness since 3 days.
H/O paresthesias in BLE (on and off) since 2 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 lordosis.

There is a posterior disc herniation, more to the left, at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing.

The L4-L5 facet joints show degenerative changes.

A posterior and a right far lateral (extraforaminal) disc herniation is seen at the L3-L4 level with anterior indentation of the thecal sac and mild right neural foraminal narrowing.

Small posterior disc bulges are noted at the L1-L2, L2-L3 and L5-S1 levels. A small left postero-lateral disc herniation is noted at the L2-L3 level.




Right far lateral (extraforaminal) disc bulges are noted at the L4-L5 and L5-S1 levels.

Schmorls nodes are seen in the dorso-lumbar region.

The lumbar intervertebral discs except at the L5-S1 level show loss of water content.

The rest of the lumbar facet joints show mild degenerative changes.

The lumbar vertebral bodies reveal normal signal intensity. 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 :

14.0 mm at L1-L2
13.0 mm at L2-L3
11.0 mm at L3-L4
6.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

1. A posterior disc herniation, more to the left at the L4-L5 level with degenerative changes of the L4-L5 facet joints.

2. A posterior and a right far lateral (extraforaminal) disc herniation at the L3-L4 level.

3. A small left postero-lateral (foraminal) disc herniation at the L2-L3 level.