sb/ke/rg/nl
Date : 00.00.00
Name of the Patient : Abc XyzKlmn / M / 34 yrs.
Referred by : Dr. Abc Xyzaubal.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE with paresthesias since 1 week.
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 lower lumbar intervertebral discs.
There is a small, postero-central disc herniation at the L5-S1 level with slight superior migration of the disc fragment, indenting the dural theca anteriorly.
There is a fairly large, postero-central and left paracentral disc herniation with peridiscal osteophytes at the L4-L5 level indenting the traversing left L5 nerve root. A fairly large sequestered disc fragment is noted in the anterior epidural space to the left of the midline at the L4 vertebral level, indenting the traversing left L4 nerve root.
A small posterior disc bulge with peridiscal osteophytes is noted at the L3-L4 level. A left far lateral disc herniation is also noted at this level.
The facet joints at the L3-L4 and L4-L5 levels appear slightly hypertrophied.
..2/.
- 2 - Scan-00006
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 :
18.0 mm at L1-L2
17.0 mm at L2-L3
15.0 mm at L3-L4
11.0 mm at L4-L5
7.0 mm at L5-S1.
IMPRESSION :
1. A small, postero-central disc herniation at the L5-S1 level with slight superior migration of the disc fragment.
2. A fairly large, postero-central and left paracentral disc herniation with peridiscal osteophytes at the L4-L5 level indenting the traversing left L5 nerve root. A fairly large sequestered disc fragment is noted in the anterior epidural space to the left of the midline at the L4 vertebral level, indenting the traversing left L4 nerve root.
3. A small posterior disc bulge with peridiscal osteophytes at the L3-L4 level with a left far lateral disc herniation at this level.
4. Slight facetal hypertrophy at the L3-L4 and L4-L5 levels.