sb/ke/nl/nl






Name of the Patient : Abc Xyz Hanslmn / M / 41 yrs.
Referred by : Dr. Abc Xyzdhwa.
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.

The cervical and dorsal spines were screened with 4 mm thick T2 Weighted sagittal images.

OBSERVATION :

There is reduction in height of the L5-S1 disc and loss of water content of the L2-L3, L4-L5 and L5-S1 intervertebral discs.

A posteriorly bulging disc with central protrusion and posterior peridiscal osteophytes is noted at the L5-S1 level with bilateral neural foraminal narrowing.

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

A small postero-central disc herniation with peridiscal osteophytes is noted at the L2-L3 level with superior migration of the disc portion along the posterior margin of the L2 vertebral body.

Slight facetal hypertrophy is noted in the lower lumbar region.

The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 :

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

Screening images of the dorsal spine do not reveal any significant feature of note.

Screening images of the cervical spine reveal a small postero-central disc herniation with peridiscal osteophytes at the C5-C6 level.

IMPRESSION :

1. A posteriorly bulging disc with central protrusion and posterior peridiscal osteophytes at the L5-S1 level.

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

3. A small postero-central disc herniation with peridiscal osteophytes at the L2-L3 level with superior migration of the disc portion along the posterior margin of the L2 vertebral body.
..3/.







- 3 - Scan-00008


4. Slight facetal hypertrophy in the lower lumbar region.

5. A small postero-central disc herniation with peridiscal osteophytes at the C5-C6 level.

As compared to the previous MRI dated 00.00.0000 (scan no:00002) there is significant decrease in the degree of disc herniation at the L5-S1 level.