ke/hs/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyz Plmn / F / 18 yrs.
Referred by : Dr. Abc Xyzhari / Dr. Abc Xyzand.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE since 3 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 a large posterior disc herniation at the L4-L5 level with anterior compression of the thecal sac and bilateral neural foraminal narrowing at this level. This disc shows loss of water content.
Mild facetal hypertrophy is seen at the L4-L5 and L5-S1 levels. A mild posterior disc bulge is noted at the L5-S1 level.
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 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 :
14.0 mm at L1-L2
15.0 mm at L2-L3
13.0 mm at L3-L4
7.0 mm at L4-L5
9.0 mm at L5-S1.
IMPRESSION :
A large posterior disc herniation with canal stenosis at the L4-L5 level.