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sb/hs/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzue Anlmn / M / 32 yrs.
Referred by : Dr. Abc Xyzddiqui.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O low back pain since 4 years with paresthesias in BLE.

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.

There is a postero-central disc herniation with a peridiscal osteophyte at the L5-S1 level.

A posteriorly extruded disc is noted at the L4-L5 level with a sequestered disc fragment in the anterior epidural space at the L5 vertebral level, more to the right of the midline, and indenting the traversing right L5 nerve root. Small posterior peridiscal osteophytes are noted at this level.

A postero-central protruded disc is noted at the L3-L4 level.

A hemangioma with fat content (hyperintense on all the pulse sequences) is noted in the L4 vertebral body.
Scan-00002



The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 S1 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

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

IMPRESSION :

1. A postero-central disc herniation with a peridiscal osteophyte at the L5-S1 level.

2. A posteriorly extruded disc at the L4-L5 level with a sequestered disc fragment in the anterior epidural space at the L5 vertebral level, more to the right of the midline and indenting the traversing right L5 nerve root.


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