Date : 00.00.00
Name of the Patient : Abc XyzK. Galmn / M / 60 yrs.
Referred by : Dr. Abc Xyzndhi.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O low back pain radiating to BLE since 1 month.
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 sacralization of the L5 vertebra which is as marked on the film.
There is slight retrolisthesis of the L3 over the L4 vertebra. Minimal forward translation of L4 over L5 vertebra is noted.
The L2-L3, L3-L4 and L4-L5 intervertebral discs show slight loss of water content.
There is a postero-central and left postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with left neural foraminal narrowing.
A posteriorly bulging disc with posterior peridiscal osteophyte is noted at the L3-L4 level with bilateral neural foraminal narrowing. A left far lateral disc bulge is also noted at this level.
A right far lateral disc herniation with peridiscal osteophytes is noted at the L2-L3 level with right neural foraminal narrowing and indentation on the extraforaminal segment of the right L2 nerve root.
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The facet joints at the L3-L4 and L4-L5 levels show hypertrophic degenerative changes bilaterally, more at the L4-L5 level. Ligamentum flavum hypertrophy is seen at the L3-L4 and L4 levels.
A schmorls node is noted along the superior margin of the L4 vertebra.
A Tarlovs perineural cyst is noted at the S1 vertebral level on the left.
The lumbar vertebral bodies and the remaining intervertebral discs 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 D12 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 :
18.0 mm at L1-L2
18.0 mm at L2-L3
16.0 mm at L3-L4
12.0 mm at L4-L5
10.0 mm at L5-S1.
1. Sacralization of the L5 vertebra.
2. Slight forward translation of L4 over L5 vertebra and retrolisthesis of the L3 over the L4 vertebra.
3. A postero-central and left postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level.
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4. A posteriorly bulging disc with posterior peridiscal osteophyte at the L3-L4 level.
5. A right far lateral disc herniation wtih peridiscal osteophytes at the L2-L3 level.
6. Hypertrophic facetal arthropathy at the L3-L4 and L4-L5 levels bilaterally.
7. Tight lumbar canal at the L3-L4 level.