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ke/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc XyzSlmn / F / 50 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE with paresthesias.
H/O fall 1 year back.

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 :

The lumbar intervertebral discs except the L1-L2 disc show loss of water content.

There is a posterior disc herniation at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing and indentation upon the traversing left L5 nerve root. Right far lateral disc herniation is also noted at this level with indentation upon the extraforaminal portion of the right L4 nerve root.

Small posterior disc herniations are seen at the L3-L4 and L5-S1 levels.

The lumbar facet joints show degenerative changes.

Type II degenerative changes are seen in the L4 and L5 vertebral bodies adjacent to the L3-L4 and L4-L5 intervertebral discs.


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

15.0 mm at L1-L2
14.0 mm at L2-L3
10.0 mm at L3-L4
9.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

1. A posterior disc herniation at the L4-L5 level indenting the traversing left L5 nerve root and a right far lateral disc herniation at this level indenting the extraforaminal portion of the right L4 nerve root.

2. Small posterior disc herniations at the L3-L4 and L5-S1 levels.


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