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ke/sb/nl/rg
Date : 00.00.00

Name of the Patient : Abc Xyzh A. lmn / M / 26 yrs.
Referred by : Dr. Abc Xyzathak.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with tingling since 1 year.
H/O fall 1 year ago.

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 a posterior and right paracentral disc extrusion at the L4-L5 level with anterior compression of the thecal sac and slight right neural foraminal narrowing. There is inferior migration of the disc which is seen to lie in the right lateral recess of the L5 vertebra with indentation upon the right L5 nerve root.

A postero-central disc herniation is seen at the L5-S1 level. There is slight inferior migration of the disc which is seen to lie posterior to the S1 vertebral body. The L5-S1 facet joints show degenerative changes.

The L4-L5 and L3-L4 facet joints show mild degenerative changes.

The L4-L5 and L5-S1 intervertebral discs show loss of water content. Posterior peridiscal osteophytes are noted at these levels.



The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of 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 S2 level.

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

16.0 mm at L1-L2
15.0 mm at L2-L3
14.0 mm at L3-L4
7.0 mm at L4-L5
7.0 mm at L5-S1.

IMPRESSION :

1. A posterior and right paracentral disc extrusion at the L4-L5 level with inferior migration of the disc in the right lateral recess of the L5 vertebra with indentation upon the right L5 nerve root.

2. A postero-central disc herniation at the L5-S1 level with slight inferior migration of the disc.

3. Posterior peridiscal osteophytes at the L4-L5 and L5-S1 levels.




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