sb/bv/rg.
Date : 00.00.00
Name of the Patient : Abc Xyzh Panthlmn / M / 40 yrs.
Referred by : Dr. Abc Xyztchha.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE (right more than left) with paresthesias since 2 weeks.
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 L1-L2, L4-L5 and L5-S1 intervertebral discs with reduction in height of these intervertebral discs.
Posterior peridiscal osteophytes are noted at the L5-S1 level, indenting the dural theca anteriorly.
There is a posterior and right postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with right neural foraminal narrowing and minimal indentation of the extraforaminal segment of the right L4 nerve root.
A large postero-central disc herniation with peridiscal osteophytes is noted at the L3-L4 level with a sequestered disc fragment in the anterior epidural space extending from the inferior half of the L3 to the superior half of the L4 vertebral body. There is resultant compression of the thecal sac at these levels.
A right paracentral disc herniation with peridiscal osteophyte is noted at the L2-L3 level.
..2/.
A posteriorly bulging disc with a peridiscal osteophyte is noted at the L1-L2 level with a right far lateral disc bulge with peridiscal osteophytes indenting the extraforaminal segment of the right L1 nerve root.
Slight facetal hypertrophy is noted on the left at the L5-S1 and bilaterally at the L4-L5 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 S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
13.0 mm at L1-L2
12.0 mm at L2-L3
5.0 mm at L3-L4
9.0 mm at L4-L5
12.0 mm at L5-S1.
IMPRESSION :
1. A large postero-central disc herniation with peridiscal osteophytes at the L3-L4 level with a sequestered disc fragment in the anterior epidural space extending from the inferior half of the L3 to the superior half of the L4 vertebral body.
2. A right paracentral disc herniation with peridiscal osteophyte at the L2-L3 level.
3. A posterior and right postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with right neural foraminal narrowing and minimal indentation of the extraforaminal segment of the right L4 nerve root.
..3/.
- 3 - Scan-00006
4. Posterior peridiscal osteophytes at the L5-S1 level.
5. A posteriorly bulging disc with a peridiscal osteophyte at the L1-L2 level and a right far lateral disc bulge with peridiscal osteophytes indenting the extraforaminal segment of the right L1 nerve root.
6. Slight facetal hypertrophy on the left at the L5-S1 level and bilaterally at the L4-L5 level.