Date : 00.00.00
Name of the Patient : Abc Xyzj Ylmn / M / 28 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 and paresthesias since 1 1/2 years.
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.
There is loss of water content of the L4-L5 intervertebral disc. There is slight retroplacement of the L4 vertebra over the L5 vertebra.
There is a small, right postero-lateral (foraminal) disc herniation at the L5-S1 level with right neural foraminal narrowing. Slight facetal hypertrophy is also noted at this level on the right side.
A right paracentral disc herniation with peridiscal osteophytes is noted at the L4-L5 level with slight inferior migration of the disc fragment indenting the traversing right L5 nerve root. Right sided facetal hypertrophy is also noted at this level.
Small right postero-lateral and right far lateral disc herniations with right neural foraminal narrowing is seen at the L4-L5 level.
Right far lateral (extraforaminal) disc bulges are noted at the L2-L3 and L3-L4 levels.
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 D12-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 :
15.0 mm at L1-L2
13.0 mm at L2-L3
15.0 mm at L3-L4
10.0 mm at L4-L5
11.0 mm at L5-S1.
1. A small, right postero-lateral (foraminal) disc herniation at the L5-S1 level with right sided facetal hypertrophy.
2. A right paracentral disc herniation with peridiscal osteophytes at the L4-L5 level with indentation of the traversing right L5 nerve root and right sided facetal hypertrophy.
3. Small right postero-lateral and right far lateral disc herniations at the L4-L5 level.