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ke/sb/rg/nl

Name of the Patient : Abc Xyz K. Jlmn / M / 55 yrs.
Referred by : Dr. Abc Xyzatt / Dr. Abc Xyzshipura.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the LLE since 3 1/2 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 a left postero-lateral disc herniation at the L5-S1 level with indentation upon the exiting left S1 nerve root and left neural foraminal narrowing. The L5-S1 facet joints appear hypertrophied.

A small focal left far lateral disc herniation is noted at the L4-L5 level and a minimal posterior disc bulge is noted at this level. Facetal hypertrophy is also noted.

The L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content.

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.
..2/.








- 2 - Scan-00002


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

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

IMPRESSION :

The MRI features are suggestive of :

1. A left postero-lateral disc herniation at the L5-S1 level with indentation upon the exiting left S1 nerve root and facetal hypertrophy at that level.

2. A small focal left far lateral disc herniation at the L4-L5 level with a small posterior disc bulge and facetal hypertrophy at that level.



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    • Interventional Pain Procedure Templates
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