Date : 00.00.00
Name of the Patient : Abc XyzThlmn / F / 70 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O radicular pain to the LLE with occasional numbness since 6 months.
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.
There appears to be sacralization of the L5 vertebra and it is as marked on the film. Please correlate with plain radiographs.
There is mild retroplacement of the L1 over the L2, L2 over the L3 and L3 over the L4 vertebrae.
The lumbar intervertebral discs show loss of water content and the L1-L2, L2-L3, L3-L4 and L4-L5 intervertebral discs are reduced in height.
A postero-central disc herniation is seen to indent the thecal sac at the L4-L5 level.
There are small posterior disc herniations with peridiscal osteophytes indenting the thecal sac and causing mild neural foraminal narrowing bilaterally at the L1-L2, L2-L3 and L3-L4 levels. The foraminal portion of the L2 and L3 nerve roots bilaterally appear impinged.
The pedicles of the lumbar vertebrae are congenitally short in their antero-posterior dimensions. Facetal hypertrophy is noted over the L1-L2 to L4-L5 levels.
The lumbar vertebral bodies show areas of fatty replacement of normal marrow suggestive of osteoporotic changes.
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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 thecal sac terminates at the S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
13.0 mm at L1-L2
11.0 mm at L2-L3
10.0 mm at L3-L4
9.0 mm at L4-L5
10.0 mm at L5-S1.
1. Sacralization of the L5 vertebra. Please correlate with plain radiographs.
2. A postero-central disc herniation with a tight canal at the L4-L5 level.
3. Small posterior disc herniations with peridiscal osteophytes and a tight canal at the L1-L2, L2-L3 and L3-L4 levels.
4. Facetal hypertrophy over the L1-L2 to L4-L5 levels.
5. Impingement of the foraminal portion of the L2 and L3 nerve roots bilaterally.
6. Congenitally short pedicles of the lumbar vertebrae in their antero-posterior dimensions.