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sb/ke/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzai Chlmn / F / 70 yrs.
Referred by : Dr. Abc Xyznjawalla.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with tingling since 6 months.

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 mild retroplacement of the L3 over the L4 vertebra.

There is loss of water content of the lower lumbar intervertebral discs.

A small, left far lateral protruded disc is noted at the L5-S1 level. The L5-S1 facet joints show mild degenerative changes, left more than right.

A minimal, postero-central and right postero-lateral disc bulge is seen at the L4-L5 level.

A small posterior disc bulge with peridiscal osteophyte is noted at the L3-L4 level.

There is minimal facet joint effusion at the L3-L4 and L4-L5 levels bilaterally.

Focal fatty marrow changes are noted adjacent to the L3-L4 and L4-L5 intervertebral disc.
..2/.







The rest of 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 L1-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 :

17.0 mm at L1-L2
18.0 mm at L2-L3
19.0 mm at L3-L4
14.0 mm at L4-L5
13.0 mm at L5-S1.

IMPRESSION :

Minimal facet joint effusion at the L3-L4 and L4-L5 levels bilaterally.

No other significant abnormality is detected on this study.

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    • Interventional Pain Procedure Templates
    • The Ultimate Guide to Rapid Reporting for FRCR 2B
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