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sb/hs/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzalmn / M / 33 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE with paresthesias since 1 year which has increased since 20-25 days.

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 water content of the L4-L5 and L5-S1 intervertebral discs.

A small posterior disc bulge is noted at the L4-L5 level.

Facetal hypertrophy is seen at the L4-L5 and L5-S1 levels bilaterally and on the right side at the L3-L4 level.

Hypointense areas on all the pulse sequences are seen within the superior aspect of the S1 vertebral body (? sclerosis - ? significance).

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 S1 level.

Fat is noted in the filum terminale at the L2 and L3 vertebral levels.

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
15.0 mm at L4-L5
14.0 mm at L5-S1.

IMPRESSION :

1. Degenerated L4-L5 disc with a small posterior disc bulge at that level.

2. Facetal hypertrophy at the L4-L5 and L5-S1 levels bilaterally and on the right side at the L3-L4 level.


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