hs/ke/nl/rg.
Date : 00.00.00
Name of the Patient : Abc Xyz Shamsulmn / F / 46 yrs.
Referred by : Dr. Abc Xyz. Kapadia.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with numbness.
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 evidence of a posterior disc herniation indenting the thecal sac and the traversing L5 nerve roots at the L4-L5 level. Also seen is bilateral neural foraminal narrowing at this level.
A left postero-lateral disc herniation is seen to narrow the left neural foramen and impinge the exiting left L3 nerve root at the L3-L4 level. A small left far lateral disc herniation is also noted at this level.
A small right postero-lateral disc herniation is seen to narrow the right neural foramen at the L5-S1 level.
The L4-L5 and L5-S1 facet joints show degenerative changes.
The lower lumbar intervertebral discs show loss of water content.
Scan-00008
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 :
19.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
10.0 mm at L4-L5
7.0 mm at L5-S1.
IMPRESSION :
1. A posterior disc herniation indenting the traversing L5 nerve roots with canal stenosis at the L4-L5 level.
2. A left postero-lateral disc herniation and a small left far lateral disc herniation at the L3-L4 level.
3. A small right postero-lateral disc herniation at the L5-S1 level.
4. Facetal arthropathy at the L4-L5 and L5-S1 levels.