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hs/ke/rg/nl
Date : 00.00.00

Name of the Patient : Abc XyzYlmn / M / 37 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache since 2 months.
H/O similar complaints 1 year ago, which was recovered.

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 large postero-central disc extrusion, more to the left of the midline and indenting the thecal sac at the L5-S1 level. A disc portion is seen to lie in the left lateral recess of S1 vertebra with resultant impingement of the traversing S1 nerve root. A disc portion is also seen to lie in the left anterior epidural space at the L5 vertebral level. The L5-S1 facet joints show mild degenerative changes.

A postero-central disc herniation is seen to indent the thecal sac at the L4-L5 level. The facet joints show mild degenerative changes.

Posterior disc bulges are noted at the L2-L3 and L3-L4 levels.

The L2-L3, L4-L5 and L5-S1 intervertebral discs show loss of water content. The L2-L3 intervertebral disc is reduced in height.


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 D12 level and the thecal sac terminates at the S1 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
15.0 mm at L3-L4
13.0 mm at L4-L5
9.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. A large postero-central disc extrusion, more to the left of the midline at the L5-S1 level with a disc portion lying in the left lateral recess of S1 vertebra with resultant impingement of the traversing S1 nerve root. A disc portion is also seen to lie in the left anterior epidural space at the L5 vertebral level.

2. Mild facetal arthropathy at the L5-S1 level with canal stenosis.

3. A postero-central disc herniation with mild facetal arthropathy at the L4-L5 level.









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