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sb/bv/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyz. Dlmn / M / 36 yrs.
Referred by : Dr. Abc Xyznji.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache since 3 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 L5-S1 intervertebral disc.

There is a small, postero-central and left paracentral disc herniation at the L5-S1 level, minimally indenting the traversing left S1 nerve root.

A small, postero-central protruded disc is noted at the L4-L5 level.

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

Facetal hypertrophy is noted in the lumbar region.

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

The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
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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 :

17.0 mm at L1-L2
17.0 mm at L2-L3
17.0 mm at L3-L4
15.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

1. A small, postero-central and left paracentral disc herniation at the L5-S1 level, minimally indenting the traversing left S1 nerve root.

2. A small, postero-central protruded disc at the L4-L5 level.

3. Facetal hypertrophy in the lumbar region.

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    • Interventional Pain Procedure Templates
    • The Ultimate Guide to Rapid Reporting for FRCR 2B
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