sb/hs/rg.
Date : 00.00.00
Name of the Patient : Abc Xyz Kalmn / F / 33 yrs.
Referred by : Dr. Abc Xyzosale.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE with paresthesias since 1 month.
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 mild retroplacement of the L4 vertebra over the L5 vertebra.
There is loss of water content of the L1-L2 and L4-L5 intervertebral discs.
There is a small, postero-central protruded disc at the L5-S1 level. Slight facetal hypertrophy is noted at this level.
There is a left paracentral disc herniation at the L4-L5 level with slight inferior migration of the disc fragment indenting the traversing left L5 nerve root. Facetal and ligamentum flavum hypertrophy is noted at this level.
A small postero-central disc herniation with peridiscal osteophytes is noted at the L1-L2 level with resultant indentation upon the thecal sac.
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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-L2 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 :
13.0 mm at L1-L2
14.0 mm at L2-L3
15.0 mm at L3-L4
8.0 mm at L4-L5
9.0 mm at L5-S1.
IMPRESSION :
The MRI features are suggestive of :
1. A small, postero-central protruded disc at the L5-S1 level with slight facetal hypertrophy.
2. A left paracentral disc herniation at the L4-L5 level with slight inferior migration of the disc fragment with indentation upon the traversing left L5 nerve root. Facetal and ligamentum flavum hypertrophy is noted at this level.
3. A small postero-central disc herniation with peridiscal osteophytes at the L1-L2 level.
4. Lumbar canal stenosis at the L4-L5 level.