sb/ke
Date : 00.00.00

Name of the Patient : Abc XyzSuleman Melmn / M / 45 yrs.
Referred by : Dr. Abc Xyzvade.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE (right more than left) with paresthesias since 3-4 years which has increased since 10-12 days.

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 D12-L1, L1-L2, L4-L5 and L5-S1 intervertebral discs.

There is minimal forward translation of the L5 over the S1 vertebra with probable spondylolysis at L5 (kindly correlate with plain radiographs).

A small, postero-central disc herniation is noted at the L5-S1 level, indenting the dural theca anteriorly. Facetal hypertrophy is noted at this level bilaterally.

A small postero-central and right paracentral disc herniation is seen at the L4-L5 level with indentation on the traversing right L5 nerve root at that level. Facetal hypertrophy is also noted at this level.

Minimal posterior disc bulge with peridiscal osteophyte is noted at the L1-L2 level.
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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 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
16.0 mm at L2-L3
15.0 mm at L3-L4
11.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. Minimal forward translation of the L5 over the S1 vertebra with probable spondylolysis at L5 (kindly correlate with plain radiographs).

2. A small, postero-central disc herniation at the L5-S1 level, with facetal hypertrophy at this level bilaterally.

3. A small postero-central and right paracentral disc herniation at the L4-L5 level with indentation on the traversing right L5 nerve root. Facetal hypertrophy is also noted at this level.

4. Tight lumbar canal at the L4-L5 and L5-S1 levels.