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sb/hs/nl
Date : 00.00.00

Name of the Patient : Abc Xyzni lmn / F / 33 yrs.
Referred by : Dr. Abc Xyzaubal.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE with numbness.

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 :

The L5 vertebral body is as marked on the film.

There is loss of water content of the L5-S1 intervertebral disc and slight loss of water content of the L2-L3 intervertebral disc.

There is a fairly large, postero-central and left paracentral extruded disc with peridiscal osteophytes at the L5-S1 level with thecal sac compression and indentation on the traversing left S1 nerve root. Slight superior migration of the disc fragment is also noted.

Type I and Type II degenerative marrow changes are noted in the L5 and S1 vertebral bodies adjacent to the L5-S1 disc. Anterior disc bulge with peridiscal osteophytes is noted at this level.








The rest of 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.

The conus medullaris terminates at the L1 level and the thecal sac terminates at the S3 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

21.0 mm at L1-L2
21.0 mm at L2-L3
20.0 mm at L3-L4
18.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

Fairly large, postero-central and left paracentral extruded disc with peridiscal osteophytes at the L5-S1 level indenting the traversing left S1 nerve root with resultant canal stenosis at this level.






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