Scan No : 0000 Date : 00.00.00
Name of the Patient : Abc Xyznd Shlmn / M / 37 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with tingling in BLE (left more than right) since August 0000.
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.
There is a right postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with antero-lateral indentation of the thecal sac. There is inferior migration of the disc fragment with impingement of the right L5 nerve root.
A left postero-lateral disc herniation with peridiscal osteophyte is noted at the L5-S1 level with left neural foraminal narrowing. The L4-L5 and L5-S1 intervertebral discs show loss of water content.
The L4-L5 and L5-S1 facet joints appear hypertrophied.
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-L1 level and the thecal sac terminates at the S2-S3 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
16.0 mm at L2-L3
16.0 mm at L3-L4
12.0 mm at L4-L5
13.0 mm at L5-S1.
1. A right postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with inferior migration of the disc fragment and impingement of the right L5 nerve root.
2. A left postero-lateral disc herniation with peridiscal osteophyte at the L5-S1 level.
3. Facetal hypertrophy at the L4-L5 and L5-S1 levels.