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sb/ke/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzu Shlmn / M / 75 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with paresthesias since 2 1/2 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 loss of water content of all the lumbar intervertebral discs except the L5-S1 disc.

There is sacralization of the L5 vertebra.

There is a postero-central and right postero-lateral disc herniation at the L4-L5 level with slight right neural foraminal narrowing. A left far lateral disc bulge is also noted at this level.

A small, posterior disc bulge with peridiscal osteophytes is noted at the L3-L4 level with slight right neural foraminal narrowing.

The lumbar vertebral bodies show spotty fatty marrow changes.

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.

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

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

Screening T2 Weighted sagittal images of the cervico-dorsal spine reveal degenerative changes in the cervical region.

IMPRESSION :

1. Sacralization of the L5 vertebra.

2. A postero-central and right postero-lateral disc herniation at the L4-L5 level with slight right neural foraminal narrowing.

3. A small, posterior disc bulge with peridiscal osteophytes at the L3-L4 level with slight right neural foraminal narrowing.

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