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sb/bv/rg/nl
Date : 00.00.00

Name of the Patient : Abc XyzMhlmn / M / 53 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE since 2 months with tingling.

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 loss of water content of all the lumbar intervertebral discs except the L5-S1 disc.

There is a left postero-lateral (foraminal) and left far lateral disc herniation at the L4-L5 level with left neural foraminal narrowing and impingement of the foraminal segment of the left L4 nerve root. A disc fragment is noted in the left neural foramen at the L4-L5 level (scans 104.8, 102.2) and also posterior to the L4 vertebral body.

A small, posterior disc bulge is noted at the L3-L4 level.

A right far lateral (extraforaminal) disc herniation is noted at the L2-L3 level indenting the extraforaminal segment of the right L2 nerve root.

A small posterior disc bulge with peridiscal osteophytes is noted at the L1-L2 level.



The left psoas muscle appears atrophied. The right psoas muscle also shows atrophy in its upper portion.

The lumbar vertebral bodies reveal normal signal intensity. 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 :

12.0 mm at L1-L2
11.0 mm at L2-L3
10.0 mm at L3-L4
10.0 mm at L4-L5
9.0 mm at L5-S1.

IMPRESSION :

1. A left postero-lateral (foraminal) and left far lateral disc herniation at the L4-L5 level with left neural foraminal narrowing and impingement of the foraminal segment of the left L4 nerve root. A disc fragment is noted in the left neural foramen at the L4-L5 level.

2. A small posterior disc bulge with peridiscal osteophytes at the L1-L2 level.

3. Atrophy of the psoas muscles (left greater than right).



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