Date : 00.00.00
Name of the Patient : Abc Xyzieve Dclmn / F / 74 yrs.
Referred by : Dr. Abc Xyzauhan.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O low back pain with radiation to the RLE and paresthesias since 0000.
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 is scoliosis of the dorso-lumbar spine with convexity to the right.
There is reduction in height of the L5-S1 intervertebral disc and loss of water content of the lumbar intervertebral discs.
A posterior disc bulge with posterior peridiscal osteophyte is noted at the L5-S1 level with bilateral neural foraminal narrowing, more on the right.
A diffuse posterior disc bulge is noted at the L4-L5 level with right neural foraminal narrowing and indentation on the extraforaminal segment of the right L4 nerve root.
A posterior and left far lateral disc bulge is noted at the L3-L4 level.
A posterior disc herniation with peridiscal osteophyte is noted at the L2-L3 level. A left far lateral disc herniation is also noted at this level.
A right far lateral disc bulge with peridiscal osteophyte is noted at the L1-L2 level with slight right neural foraminal narrowing.
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The right facet joints at the L4-L5 and L5-S1 levels appear slightly hypertrophied.
The rest of the lumbar vertebral bodies show spotty fatty marrow changes. 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.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
16.0 mm at L1-L2
15.0 mm at L2-L3
14.0 mm at L3-L4
12.0 mm at L4-L5
7.0 mm at L5-S1.
1. A posterior disc bulge with posterior peridiscal osteophyte at the L5-S1 level with bilateral neural foraminal narrowing.
2. A diffuse posterior disc bulge at the L4-L5 level with indentation on the extraforaminal segment of the right L4 nerve root.
3. A posterior and left far lateral disc bulge at the L3-L4 level.
4. A posterior disc herniation with peridiscal osteophyte at the L2-L3 level with a left far lateral disc herniation at this level.
5. A right far lateral disc bulge with peridiscal osteophyte at the L1-L2 level with
6. Spotty fatty marrow changes in the lumbar vertebrae suggests osteoporotic changes.