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Date : 00.00.00

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

CLINICAL PROFILE :

C/O backache since 14 years.
C/O radicular pain to BLE (left more than right) with paresthesias since 2-3 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 L2-L3 and L3-L4 intervertebral discs.

There is slight anterior wedging of the L2 vertebral body without change in signal intensity. Resultant slight kyphus is noted at this level.

There is a fairly large, left paracentral disc herniation with a peridiscal osteophyte at the L2-L3 level, indenting the anterior dural theca and narrowing the left neural foramen at that level. Probable indentation on the traversing left L3 nerve root is noted.

A small, posterior disc bulge is noted at the L3-L4 level. A transepiphyseal herniation is seen at the antero-superior portion of the L4 vertebra.

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

The conus medullaris terminates at the L2 level and the thecal sac terminates at the S3 level.

Fat is noted in the filum terminal from the L3 to S3 vertebral levels.
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The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

17.0 mm at L1-L2

13.0 mm at L2-L3

14.0 mm at L3-L4

15.0 mm at L4-L5

12.0 mm at L5-S1.

IMPRESSION :

1. Anterior wedging of the L2 vertebral body without change in signal intensity, may be the sequelae of previous trauma.

2. A fairly large, left paracentral disc herniation with a peridiscal osteophyte at the L2-L3 level, with probable indentation on the traversing left L3 nerve root.

3. Fat in filum terminal over the L3 to S3 vertebral levels.




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