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hs/bv/nl/nl
Date : 00.00.00

Name of the Patient : Abc XyzSollmn / M / 65 yrs.
Referred by : Dr. Abc Xyzhansali.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE 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 mild retroplacement of the L2 vertebra over the L3 vertebra. The lumbar intervertebral discs except at the L5-S1 level show loss of water content.

Posterior disc herniations are seen to indent the thecal sac and narrow both neural foramina at the L2-L3 and L3-L4 levels.

A small posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level.

Bilateral far lateral (extraforaminal) disc herniations are seen at the L3-L4 and L4-L5 levels and on the right side at the L2-L3 level. Far lateral (extraforaminal) disc bulges are seen on the left side at the L2-L3 level and on the right side at the L1-L2 level.

A posterior disc bulge is seen at the L1-L2 level.



There is facetal hypertrophy at the L2-L3, L3-L4 and L4-L5 levels.

Anterior disc herniations are noted in the lumbar region.

The lumbar vertebral bodies reveal normal signal intensity. The remaining 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 :

14.0 mm at L1-L2
14.0 mm at L2-L3
13.0 mm at L3-L4
12.0 mm at L4-L5
13.0 mm at L5-S1.

IMPRESSION :

1. Retroplacement of the L2 over the L3 vertebra.

2. Posterior disc herniations at the L2-L3 and L3-L4 levels.

3. A small posterior disc herniation at the L4-L5 level.

4. Hypertrophic facetal arthropathy at the L2-L3, L3-L4 and L4-L5 levels.

5. Tight canal at the L2-L3, L3-L4 and L4-L5 levels.



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