Date : 00.00.00
Name of the Patient : Abc Xyzxmi Mlmn / F / 75 yrs.
Referred by : Dr. Abc Xyzhah / Dr. Abc Xyzehta.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE 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 is slight forward translation of the L5 over the S1 vertebra.
A postero-central and a left far lateral disc protrusion is seen at the L5-S1 level with anterior indentation of the thecal sac. The L5-S1 facet joints bilaterally show degenerative changes with hypertrophic changes on the left side. There is resultant indentation upon the foraminal portion of the left L5 nerve root. Mild ligamentum flavum hypertrophy is also noted at this level.
There is slight retroplacement of the L1 over the L2 vertebra. A pseudoposterior disc herniation is seen at the L1-L2 level with anterior indentation of the thecal sac. Posterior peridiscal osteophytes are also noted at this level.
Small posterior disc bulges are seen at the L2-L3, L3-L4 and L4-L5 levels. The facet joints at these levels show mild degenerative changes. Ligamentum flavum hypertrophy is noted at the L4-L5 level.
The lumbar intervertebral discs show loss of water content.
Diffuse fatty changes are seen in the dorso-lumbar vertebrae, suggestive of osteoporosis. Slight wedging of the D9, D10, D11 and D12 vertebral bodies is noted.
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The remaining facet joints and 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 :
13.0 mm at L1-L2
15.0 mm at L2-L3
15.0 mm at L3-L4
15.0 mm at L4-L5
13.0 mm at L5-S1.
1. Slight forward translation of the L5 over the S1 vertebra.
2. A postero-central and a left far lateral disc protrusion at the L5-S1 level with degenerative changes of the L5-S1 facet joints bilaterally and hypertrophic changes on the left side with resultant indentation upon the foraminal portion of the left L5 nerve root.
3. Slight retroplacement of the L1 over the L2 vertebra with a pseudoposterior disc herniation and posterior peridiscal osteophytes at the L1-L2 level.
4. Small posterior disc bulges at the L2-L3, L3-L4 and L4-L5 levels with mild degenerative changes of the facet joints at these levels.
5. Osteoporotic changes in the dorso-lumbar spine with slight wedging of the D9 and D12 vertebrae.