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ke/hs/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz Kanlmn / M / 30 yrs.
Referred by : Dr. Abc Xyzrani.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE with paresthesias in BLE (right more than left) since 3-4 months.

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 appears to be sacralization of the L5 vertebra and the L2 vertebral body is as marked on the film. Please correlate with plain radiographs.

A posterior disc herniation with posterior peridiscal osteophytes is seen at the L4-L5 level with anterior indentation of the thecal sac. Slight inferior migration of the disc is noted. This disc shows loss of water content.

The L5-S1 facet joints show degenerative changes. A mild posterior disc bulge is noted at this 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 :

16.0 mm at L1-L2
13.0 mm at L2-L3
14.0 mm at L3-L4
11.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. Probable sacralization of the L5 vertebra. Please correlate with plain radiographs.

2. A posterior disc herniation with posterior peridiscal osteophytes at the L4-L5 level with slight inferior migration of the disc.

3. Facetal arthropathy at the L5-S1 level bilaterally.

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