Date : 00.00.00
Name of the Patient : Abc Xyz S. Chidaklmn / F / 63 yrs.
Referred by : Dr. Abc Xyznna / Dr. Abc Xyz. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since December 0000.
H/O fall 2 years 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 sacralization of the L5 vertebra and the L1 vertebral body is as marked on the film.
There is slight forward subluxation of the L4 over the L5 vertebra.
Posterior and bilateral far lateral disc bulge is seen at the L4-L5 level with anterior indentation of the thecal sac and on the extraforaminal portion of the L4 nerve roots bilaterally.
There is a posterior and a right far lateral disc bulge at the L3-L4 level with slight anterior indentation of the thecal sac.
Hypertrophic facetal arthropathy is noted at the L3-L4 and L4-L5 levels.
Small anterior disc herniations are noted at the L2-L3, L3-L4 and L4-L5 levels. These intervertebral discs show loss of water content.
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.
Fat is noted within the filumm terminale at the L1 and L2 levels and this may be a normal variant.
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 :
18.0 mm at L1-L2
18.0 mm at L2-L3
14.0 mm at L3-L4
14.0 mm at L4-L5
9.0 mm at L5-S1.
1. Sacralization of the L5 vertebra.
2. Slight forward subluxation of the L4 over the L5 vertebra.
3. Posterior and bilateral far lateral disc bulge at the L4-L5 level with indentation upon the extraforaminal portion of the L4 nerve roots bilaterally.
4. A posterior and a right far lateral disc bulge at the L3-L4 level.
5. Hypertrophic facetal arthropathy at the L3-L4 and L4-L5 levels.