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ke/bv/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzlmn / M / 25 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE since 4 years.

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 normal lumbar lordosis.

There is a posterior disc herniation with posterior peridiscal osteophytes at the L4-L5 level with anterior indentation of the thecal sac. Slight inferior migration of the disc is noted posterior to the L5 vertebra with indentation upon the right L5 nerve root. This disc is dessicated.

A small postero-central disc protrusion is noted at the L5-S1 level.

The lumbar vertebral bodies and the intervertebral discs reveal normal signal intensity. The facet joints and visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1 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 :

17.0 mm at L1-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
12.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. A posterior disc herniation with posterior peridiscal osteophytes at the L4-L5 level inferior migration of the disc posterior to the L5 vertebra indenting the right L5 nerve root.

2. A small postero-central disc protrusion at the L5-S1 level.


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