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sb/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzra lmn / M / 60 yrs.
Referred by : Dr. Abc Xyzagwati.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache and neckpain with pain radiating to the RUE and RLE with claudication.

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 lumbar intervertebral discs.

There is a very small, left paracentral disc herniation at the L5-S1 level with minimum indentation on the traversing left S1 nerve root.

There is a small posterior disc bulge with a left postero-lateral (foraminal) disc protrusion at the L4-L5 level narrowing the left neural foramen at that level.

There is a left far lateral (extraforaminal) disc herniation at the L3-L4 level with minimum indentation on the extraforaminal segment of the left L3 nerve root.

A small posterior peridiscal osteophyte is noted at the L1-L2 level.


Focal fatty marrow changes are noted in the L2 and L4 vertebral bodies.

The rest of the lumbar vertebral bodies reveal normal signal intensity. 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 :

18.0 mm at L1-L2
19.0 mm at L2-L3
19.0 mm at L3-L4
17.0 mm at L4-L5
16.0 mm at L5-S1.

IMPRESSION :

1. A very small, left paracentral disc herniation at the L5-S1 level with minimum indentation on the traversing left S1 nerve root.

2. A small posterior disc bulge with a left postero-lateral (foraminal) disc protrusion at the L4-L5 level.

3. A left far lateral (extraforaminal) disc herniation at the L3-L4 level with minimum indentation on the extraforaminal segment of the left L3 nerve root.



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