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Date : 00.00.00

Name of the Patient : Abc Xyzllah Chaudlmn / M / 50 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Dorsal Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE (right more than left) with paresthesias since 2 years.
H/O fall.

EXAMINATION :

M.R.I of the dorsal spine was performed using the following parameters :

5 mm thick T1 Weighted and T2 Weighted sagittal images.

5 mm and 8 mm thick T2 Weighted axial images.

OBSERVATION :

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

The dorsal spinal cord reveals normal signal intensity.

The conus medullaris terminates at the L2 level.

The lumbar spine was screened with 5 mm thick T1 Weighted sagittal images and 5 mm thick T2 Weighted axial images. There is a posterior and right postero-lateral disc herniation at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing, right more than left. There is indentation upon the foraminal and extraforaminal portion of the right L4 nerve root. A small portion of the disc is seen to lie in the right lateral recess of L5 vertebra with impingement of the right L5 nerve root.
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There is a posterior and left postero-lateral disc herniation at the L5-S1 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing, left more than right.
There is indentation upon the foraminal and extraforaminal portion of the left L5 nerve root. There is suggestion of inflammation of left L5 nerve root.

A small postero-central disc herniation is seen at the L1-L2 level with mild superior migration of the disc.

The lumbar facet joints show mild degenerative changes.

IMPRESSION :

1. No significant abnormality is detected within the dorsal spine.

2. A posterior and right postero-lateral disc herniation at the L4-L5 level with indentation upon the foraminal and extraforaminal portion of the right L4 nerve root. A small portion of the disc is seen to lie in the right lateral recess of L5 vertebra with impingement of the right L5 nerve root.

3. A posterior and left postero-lateral disc herniation at the L5-S1 level with indentation upon the foraminal and extraforaminal portion of the left L5 nerve root.

4. A small postero-central disc herniation at the L1-L2 level with mild superior migration of the disc.

5. Mild facetal arthropathy in the lumbar region.




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