Date : 00.00.00
Name of the Patient : Abc Xyzli Anlmn / M / 55 yrs.
Referred by : Dr. Abc Xyzwalla.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since 6-7 years.
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 lumbar spine with convexity to the right.
There is reduction in height and loss of water content of all the lumbar intervertebral discs except the L5-S1 disc. Some of the lumbar intervertebral discs show a hypointense signal on all the pulse sequences suggesting calcium/vacuum phenomena.
Posterior disc bulges with posterior peridiscal osteophytes are noted at the L1-L2, L2-L3, L3-L4 and L4-L5 levels with bilateral neural foraminal narrowing. Left far lateral disc bulges with peridiscal osteophytes are also noted at these levels.
A right postero-lateral and far lateral disc herniation is seen at the L3-L4 level indenting the traversing right L4 nerve root.
The right facet joint at the L4-L5 level and the facet joints at the L3-L4 level bilaterally show hypertrophic degenerative changes.
Type II degenerative marrow changes are noted adjacent to the L2-L3 and L4-L5 intervertebral discs.
A small hypointense focus on all the pulse sequences in the right sacral ala most likely represents a bone island. Similar lesion is noted in the D11 vertebral body, posteriorly.
The rest of the lumbar vertebral bodies reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12-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 :
18.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
14.0 mm at L4-L5
13.0 mm at L5-S1.
Degenerative disease of the lumbar spine with :
1. Scoliosis of the lumbar spine with convexity to the right.
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2. Posterior disc bulges with posterior peridiscal osteophytes over the L1-L2 to L4-L5 levels with bilateral neural foraminal narrowing. Left far lateral disc bulges with peridiscal osteophytes are also noted at these levels.
3. A right postero-lateral and far lateral disc herniation at the L3-L4 level indenting the traversing right L4 nerve root.
4. Hypertrophic facetal arthropathy at the L4-L5 level on the right side and at the L3-L4 level bilaterally.
5. Lumbar canal stenosis at the L3-L4 and L4-L5 levels.