sb/ke
Date : 00.00.00

Name of the Patient : Abc Xyz R. Shlmn / M / 43 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with radiation of pain to the RLE with paresthesias since 1 month.
H/O lifting heavy weights.

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

There is a postero-central and right paracentral disc herniation at the L5-S1 level with slight inferior migration of the disc fragment indenting the traversing right S1 nerve root. Bilateral far lateral disc bulges are noted at this level.

A fairly large, posteriorly herniated disc with peridiscal osteophyte is noted at the L4-L5 level, indenting the dural theca anteriorly. A sequestered disc fragment is noted in the anterior epidural space to the right of the midline at the L5 vertebral level, compressing the thecal sac and indenting the traversing right L5 nerve root. A left far lateral disc bulge is also noted at this level.



A haemangioma with fat content is noted in the D12 vertebral body.

Type II degenerative marrow changes are noted adjacent to the L4-L5 and L5-S1 intervertebral discs.

Slight facetal hypertrophy is noted at the L4-L5 level.

The rest of the lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1 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 :

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

IMPRESSION :

1. A postero-central and right paracentral disc herniation at the L5-S1 level with slight inferior migration of the disc fragment indenting the traversing right S1 nerve root. Bilateral far lateral disc bulges are noted at this level.

2. A fairly large, posteriorly herniated disc with peridiscal osteophyte at the L4-L5 level with a sequestered disc fragment in the anterior epidural space to the right of the midline at the L5 vertebral level, indenting the traversing right L5 nerve root.

3. Slight facetal hypertrophy at the L4-L5 level.