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ke/sb/nl/rg.
/890 Date : 00.00.00

Name of the Patient : Abc Xyz lmn / M / 38 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE with paresthesias.

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 L1-L2, L4-L5 and L5-S1 intervertebral discs.

There is slight forward translation of the L5 over the S1 vertebral body. Spondylolysis is noted at the L5, bilaterally.

A diffuse posterior disc herniation is seen at the L5-S1 level with posterior peridiscal osteophytes and anterior indentation of the thecal sac. Anterior disc herniation is also noted at this level.

The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12-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 :

21.0 mm at L1-L2
20.0 mm at L2-L3
21.0 mm at L3-L4
18.0 mm at L4-L5
16.0 mm at L5-S1.

The cervico-dorsal spine was screened with 5 mm thick T2 Weighted sagittal images. Posterior disc herniation is noted at the C6-C7 level.

IMPRESSION :

1. Slight forward translation of the L5 over the S1 vertebral body with spondylolysis at L5, bilaterally.

2. A diffuse posterior disc herniation at the L5-S1 level with posterior peridiscal osteophytes.

As compared to the previous MRI dated 00.00.00, there is no significant change noted.
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    • Interventional Pain Procedure Templates
    • The Ultimate Guide to Rapid Reporting for FRCR 2B
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