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ke/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc XyzPatlmn / M / 60 yrs.
Referred by : Dr. Abc Xyzagwati.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the LLE.

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 show slight loss of water content.

There is a posterior and a left postero-lateral disc herniation at the L4-L5 level with anterior indentation of the thecal sac and the left L5 nerve root. A part of the disc is seen in the left lateral recess of L5 (scans 102.2, 104.7, 106.5-6) with impingement of the left L5 nerve root. There is mild ligamentum and facetal hypertrophy with tight lumbar canal at this level.

A small posterior disc bulge is noted at the L5-S1 level.

A left far lateral disc bulge is seen at the L3-L4 level.

The lumbar vertebral bodies reveal normal signal intensity.
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 :

17.0 mm at L1-L2
15.0 mm at L2-L3
14.0 mm at L3-L4
12.0 mm at L4-L5
15.0 mm at L5-S1.

IMPRESSION :

A posterior and a left postero-lateral disc herniation at the L4-L5 level with impingement of the left L5 nerve root with a part of the disc in the left lateral recess of L5 and tight lumbar canal.


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