sb/hs/rg/nl

Name of the Patient : Abc Xyz Dhlmn / M / 37 yrs.
Referred by : Dr. Abc Xyzaubal.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE.

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 reduction in height and loss of water content of the L5-S1 intervertebral disc.

There are fairly large postero-central and left paracentral disc herniations with peridiscal osteophytes at the L5-S1 level with slight inferior migration of the disc fragment indenting the traversing left S1 nerve root. Slight facetal hypertrophy is noted at this level.

A small postero-central disc herniation with peridiscal osteophytes is noted at the L4-L5 level with slight facetal hypertrophy at this level.

A minimal posterior disc bulge is noted at the L3-L4 level.

The lumbar vertebral bodies show preponderance of hematopoeitic marrow (hypointense on the T1 Weighted images). The remaining intervertebral discs reveal normal signal intensity. The rest of 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 S2 level.

A Tarlovs perineural cyst is noted at the S2-S3 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

20.0 mm at L1-L2
19.0 mm at L2-L3
17.0 mm at L3-L4
13.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. Fairly large postero-central and left paracentral disc herniations with peridiscal osteophytes at the L5-S1 level with slight inferior migration of the disc fragment indenting the traversing left S1 nerve root with slight facetal hypertrophy at this level.

2. A small postero-central disc herniation with peridiscal osteophytes at the L4-L5 level with slight facetal hypertrophy at this level.