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sb/ke/rg.

Name of the Patient : Abc Xyz. Karim Shlmn / M / 36 yrs.
Referred by : Dr. Abc Xyzvade.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE with paresthesias since 3 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 is loss of normal lumbar lordosis and loss of water content of the L5-S1 intervertebral disc.

There is minimal forward translation of the L5 over S1 vertebra without obvious spondylolysis.

There is a fairly large, postero-central and right paracentral disc herniation at the L5-S1 level with thecal sac compression and indentation on the traversing right S1 nerve root.

A minimal posterior disc bulge is noted at the L4-L5 level.

A probable, conjoint left L5/S1 nerve root is noted.

Fat is noted in the filum terminale at the L3 vertebral 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.
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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
14.0 mm at L2-L3
12.0 mm at L3-L4
12.0 mm at L4-L5
6.0 mm at L5-S1.

Screening T1 Weighted coronal images of the sacro-iliac joints do not reveal any significant feature of note.

IMPRESSION :

1. Minimal forward translation of the L5 over S1 vertebra without obvious spondylolysis.

2. A fairly large, postero-central and right paracentral disc herniation at the L5-S1 level indenting the traversing right S1 nerve root.

3. A probable, conjoint left L5/S1 nerve root.

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