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Date : 00.00.00

Name of the Patient : Abc Xylmn / M / 45 yrs.
Referred by : Dr. Abc Xyzbrani.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O pain in the right hip joint since 2 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.

The hip joints were screened with 5 mm thick T1 Weighted and STIR coronal images.

OBSERVATION :

There is slight loss of water content of the L5-S1 intervertebral disc.

Posteriorly bulging discs are noted at the L4-L5 and L5-S1 levels with minimal indentation on the anterior dural theca. Slight hypertrophy of the facet joints at these levels is also noted.

Type II degenerative change is noted in the antero-superior portion of the L5 vertebral body.

Fat is noted in the filum terminale at the L3-L4 level.

The lumbar vertebral bodies and the remaining intervertebral discs show 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 D12-L1 level and the theca sac terminates at the S2 level.


- 2 -

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

16.0 mm at L1-L2

16.0 mm at L2-L3

15.0 mm at L3-L4

11.0 mm at L4-L5

8.0 mm at L5-S1.

Screening images of the hip hoints reveal an ill-defined hypointense signal on the T1 Weighted images in the left iliac bone adjacent to the left sacro-iliac joint. This lesion appears hyperintense on the STIR images.

Bone islands are noted in the head of the right femur. No other significant abnormality is detected in the hip joints on either side.

IMPRESSION :

1. Posteriorly bulging discs at the L4-L5 and L5-S1 levels with slight facetal hypertrophy at these levels.

2. Altered signal in the iliac bone adjacent to the left sacro-iliac joint may suggest sacro-ilitis.

If clinically indicated a dedicated study of the sacro-iliac joints would be worthwhile.

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