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sb/ke/rg.
Date : 00.00.00

Name of the Patient : Abc XyzPlmn / M / 77 yrs.
Referred by : Dr. Abc Xyzmpat.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain in the LLE with paresthesias since 3-4 years.

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 lumbar intervertebral discs.

A small, posterior disc protrusion is noted at the L5-S1 level. A sequestered disc fragment is noted in the right antero-lateral epidural space at the L5-S1 level indenting the traversing right S1 nerve root.

Small posterior disc herniations are noted at the L3-L4 and L4-L5 levels with slight bilateral neural foraminal narrowing.

A small left and right postero-lateral disc bulge is seen at the L2-L3 level.

The facet joints at the L3-L4, L4-L5 and L5-S1 levels appear hypertrophied with slight ligamentum flavum hypertrophy at the L4-L5 level.

The lumbar vertebral bodies reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
..2/.







The conus medullaris terminates at the D12-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
13.0 mm at L2-L3
13.0 mm at L3-L4
13.0 mm at L4-L5
14.0 mm at L5-S1.

IMPRESSION :

1. A small, posterior disc protrusion at the L5-S1 level with a sequestered disc fragment in the right antero-lateral epidural space at the L5-S1 level indenting the traversing right S1 nerve root.

2. Small posterior disc herniations at the L3-L4 and L4-L5 levels with slight bilateral neural foraminal narrowing.

3. A small left and right postero-lateral disc bulge at the L2-L3 level.

4. Facetal hypertrophy at the L3-L4, L4-L5 and L5-S1 levels with slight ligamentum flavum hypertrophy at the L4-L5 level.

5. Canal stenosis at the L2-L3, L3-L4 and L4-L5 levels.








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    • Interventional Pain Procedure Templates
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