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ke/hs/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzlmn / M / 24 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with paresthesias in BLE since 1 month.

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 forward translation of the L5 vertebra over the S1 vertebra and mild retroplacement of the L4 vertebra over the L5 vertebra.

A right paracentral disc herniation is seen at the L5-S1 level with indentation upon the thecal sac and the traversing right S1 nerve root.

A posterior disc herniation is noted at the L4-L5 level with anterior indentation of the thecal sac.

A large posterior disc herniation is seen at the L3-L4 level with compression of the thecal sac and resultant canal stenosis. Superior and inferior migration of a disc is noted.

The L3-L4 facet joints bilaterally and the left L4-L5 facet joint show degenerative changes.
Scan-00004


A left far lateral (extraforaminal) disc herniation is seen at the L3-L4 level.

A small left paracentral disc herniation is seen at the L2-L3 level. A postero-central disc protrusion is noted at the L1-L2 level. The lumbar intervertebral discs show loss of water content.

The lumbar vertebral bodies 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 :

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

IMPRESSION :

1. Forward translation of the L5 vertebra over the S1 vertebra and mild retroplacement of the L4 vertebra over the L5 vertebra.

2. A right paracentral disc herniation at the L5-S1 level with indentation upon the traversing right S1 nerve root.
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- 3 - Scan-00004


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

4. A large posterior disc herniation at the L3-L4 level with canal stenosis.

5. A small left paracentral disc herniation at the L2-L3 level.

6. A postero-central disc protrusion at the L1-L2 level.

7. Facetal arthropathy at the L3-L4 level bilaterally and at the L4-L5 level on the left side.

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