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hs/sb/nl/nl
Date : 00.00.00

Name of the Patient : Abc XyzGhlmn / M / 32 yrs.
Referred by : Dr. Abc Xyzwhale.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with radiation of pain to the RLE with paresthesias.

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 :

A large postero-central disc extrusion is seen to compress upon the thecal sac at the L4-L5 level. A disc portion is seen to lie within the anterior epidural space at the L4 and L5 vertebral levels.

The L3-L4 facet joint on the left side shows hypertrophic degenerative changes. The L4-L5 and L5-S1 facet joints show mild degenerative changes.

Bilateral far lateral (extraforaminal) disc bulges are noted at the L4-L5 level. The L4-L5 intervertebral disc shows loss of water content.

There is a posterior disc bulge at the L5-S1 level.

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 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 :

19.0 mm at L1-L2
19.0 mm at L2-L3
18.0 mm at L3-L4
10.0 mm at L4-L5
16.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. A large postero-central disc extrusion with canal stenosis at the L4-L5 level. A disc portion is seen to lie within the anterior epidural space at the L4 and L5 vertebral levels.

2. Hypertrophic facetal arthropathy on the left side at the L3-L4 level.

3. Mild facetal arthropathy at the L4-L5 and L5-S1 levels.
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