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ke/bv/rg/nl
Date : 00.00.00

Name of the Patient : Abc XyzJalmn / M / 46 yrs.
Referred by : Dr. Abc Xyz Sane.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias since 1-2 years.

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 sacralization of the L5 vertebral body and the L3 vertebral body is as marked on the film.

The L3-L4 and L4-L5 intervertebral discs show loss of water content.

Posterior disc herniations with small posterior peridiscal osteophytes are seen at the L3-L4 and the L4-L5 levels with anterior indentation of the thecal sac and bilateral neural foraminal narrowing.

A left far lateral disc bulge is seen at the L3-L4 level with indentation upon the extraforaminal portion of the left L3 nerve root.

An anterior disc herniation is seen at the L4-L5 level.

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.
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The conus medullaris terminates at the D12 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
15.0 mm at L2-L3
11.0 mm at L3-L4
11.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. Sacralization of the L5 vertebra.

2. Posterior disc herniations at the L3-L4 and the L4-L5 levels.

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    • Interventional Pain Procedure Templates
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