Date : 00.00.00
Name of the Patient : Abc Xyza Halmn / F / 62 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias and burning sensation since 4-5 months.
H/O fall 7-8 months back.
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 slight forward translation of the L4 over the L5 and L5 over the S1 vertebra.
There is a posterior and left postero-lateral disc herniation with peridiscal osteophytes
at the L5-S1 level with anterior indentation of the thecal sac and left neural foraminal narrowing. There is resultant indentation upon the foraminal and the extraforaminal portion of the left L5 nerve root. The L5-S1 facet joints on the left side show degenerative changes.
A diffuse posterior disc herniation with peridiscal osteophyte is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L4-L5 facet joints show mild degenerative changes.
A small postero-central disc herniation is noted at the L3-L4 level and posterior disc bulge at the L2-L3 level.
The lumbar intervertebral discs show loss of water content.
The lower lumbar vertebrae show Type II degenerative changes.
Hemangiomas with fatty content is seen in the D12 and L2 vertebral bodies.
The rest of the lumbar vertebral bodies show normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
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The conus medullaris terminates at the L2 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
16.0 mm at L2-L3
15.0 mm at L3-L4
13.0 mm at L4-L5
12.0 mm at L5-S1.
Slight atrophy of the paraspinal muscles is noted in the lower lumbar region.
1. Slight forward translation of the L4 over the L5 and L5 over the S1 vertebra.
2. A posterior and left postero-lateral disc herniation with peridiscal
osteophytes at the L5-S1 level with resultant indentation upon the foraminal and the extraforaminal portion of the left L5 nerve root and facetal arthropathy on the left side at this level.
3. A diffuse posterior disc herniation with peridiscal osteophyte at the L4-L5 level with mild facetal arthropathy at this level.
4. A small postero-central disc herniation at the L3-L4 level.