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sb/hs/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzrif lmn / M / 33 yrs.
Referred by : Dr. Abc Xyzaj.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the LLE 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 mild retroplacement of the L5 vertebra over the S1 vertebra.

There is loss of normal lumbar lordosis and slight loss of water content of the L4-L5 and L5-S1 intervertebral discs.

There is a small posteriorly herniated disc with peridiscal osteophytes at the L5-S1 level with slight right neural foraminal narrowing and minimal indentation on the extraforaminal segment of the exiting right L5 nerve root.

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

Facetal hypertrophy is noted at the L3-L4, L4-L5 and L5-S1 levels.

Bilateral far lateral (extraforaminal) disc bulges are noted at the L4-L5 and L5-S1 levels.

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.
..2/.





The conus medullaris terminates at the 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
17.0 mm at L2-L3
17.0 mm at L3-L4
15.0 mm at L4-L5
12.0 mm at L5-S1.

IMPRESSION :

1. A small posteriorly herniated disc with peridiscal osteophytes at the L5-S1 level with minimal indentation on the extraforaminal segment of the exiting right L5 nerve root.

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

3. Facetal hypertrophy at the L3-L4, L4-L5 and L5-S1 levels.

4. Bilateral far lateral (extraforaminal) disc bulges at the L4-L5 and L5-S1 levels.


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    • Interventional Pain Procedure Templates
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