w Date : 00.00.00
Name of the Patient : Abc Xyzp Klmn / M / 45 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE since 1 week.
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 the L2 vertebral body is as marked on the film. Please correlate with plain radiographs.
There is reduction in height and loss of water content of the L4-L5 intervertebral disc. The remaining lumbar intervertebral discs show slight loss of water content.
A posterior disc herniation with peridiscal osteophytes is noted at the L4-L5 level with anterior indentation upon the thecal sac. Bilateral far lateral (extraforaminal) disc herniations are also seen at this level. The L4-L5 facet joints show degenerative changes with ligamentum flavum hypertrophy at the L4-L5/L5 levels.
Small posterior peridiscal osteophytes are noted at the L3-L4 level.
Schmorls nodes are seen at the superior and inferior aspect of the D12 vertebral body.
- 2 -
The lumbar vertebral bodies reveal 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 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 :
20.0 mm at L1-L2
20.0 mm at L2-L3
15.0 mm at L3-L4
11.0 mm at L4-L5
9.0 mm at L5-S1.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebra.
2. A posterior disc herniation with peridiscal osteophytes at the L4-L5 level with facetal arthropathy at this level.
3. Ligamentum flavum hypertrophy at the L4-L5/L5 levels.
4. Bilateral far lateral (extraforaminal) disc herniations at the L4-L5 level.