bv/ke/rg/nl
Date : 00.00.00
Name of the Patient : Abc XyzDSlmn / M / 28 yrs.
Referred by : Dr. Abc Xyzpadia.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE since 2-3 months.
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 L5-S1 intervertebral disc. The L5-S1 intervertebral disc appears reduced in height.
The L5 vertebra is as marked on the film.
There is a posterior and left paracentral disc herniation with peridiscal osteophytes at the L5-S1 level with indentation on the anterior aspect of the thecal sac and the left S1 nerve root.
A posterior disc bulge is seen at the L4-L5 level.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
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The conus medullaris terminates at the 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 :
18.0 mm at L1-L2
18.0 mm at L2-L3
15.0 mm at L3-L4
15.0 mm at L4-L5
14.0 mm at L5-S1.
IMPRESSION :
1. The L5 vertebra is as marked on the film.
2. A posterior and left paracentral disc herniation with peridiscal osteophytes at the L5-S1 level with indentation upon the thecal sac and left S1 nerve root.