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sb/bv/rg.
Date : 00.00.00

Name of the Patient : Abc Xyza Glmn / F / 37 yrs.
Referred by : Dr. Abc Xyzhatt / Dr. Abc Xyzhipura.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache since 13 years (on & off) radiating to the RLE since 4-5 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 partial sacralization of the L5 vertebral body with the L5 vertebral body as marked on the film.

There is loss of water content of the L4-L5 and L5-S1 intervertebral discs.

There is a right postero-lateral (foraminal) disc herniation at the L5-S1 level with slight inferior migration of the disc fragment, indenting the traversing right S1 nerve root, which is probably inflamed (scan 105.2-4, 106.4-6, 103.6, 102.6_).

A small, postero-central protruded disc is noted at the L4-L5 level.

The lumbar vertebral bodies appear slightly hypointense when compared to the normal fatty marrow on the T1 Weighted images which may suggest conversion/preponderance of the haemopoietic marrow.

The remaining intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
..2/.





The conus medullaris terminates at the L1-L2 level and the thecal sac terminates at the S1-S2 level.

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

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

IMPRESSION :

1. A right postero-lateral (foraminal) disc herniation at the L5-S1 level with slight inferior migration of the disc fragment, indenting the traversing right S1 nerve root, which is probably inflamed.

2. A small, postero-central protruded disc at the L4-L5 level.


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