Date : 00.00.00
Name of the Patient : Abc Xyz K. Kallmn / M / 70 yrs.
Referred by : Dr. Abc Xyzah / Dr. Abc Xyz
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O low back pain since 18 years, increased since 2 years with difficulty in bending forward.
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 left. There is reduction in height and loss of water content of the lumbar intervertebral discs.
The lumbar discs show evidence of calcium/vacuum phenomena.
There is a postero-central and right postero-lateral disc herniation with peridiscal osteophyte at the L4-L5 level with right neural foraminal narrowing and indentation on the extraforaminal segment of the right L4 nerve root.
Posterior and bilateral far lateral peridiscal osteophytes are noted at the L5-S1 level.
Small, posterior peridiscal osteophytes are noted at the L1-L2, L2-L3 and L3-L4 levels.
Anterior disc herniatoins with anterior peridiscal osteophytes are noted in the lumbar region.
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The right facet joints at the L5-S1 level appears slightly hypertrophied.
Haemangiomas with fatty content are seen at the L2 and L3 vertebral levels on the right side.
Type III degenerative marrow changes (sclerosis) are noted adjacent to the L2-L3 disc.
The rest of 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 S3 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
17.0 mm at L2-L3
16.0 mm at L3-L4
13.0 mm at L4-L5
13.0 mm at L5-S1.
1. Scoliosis of the lumbar spine with convexity to the left.
2. A postero-central and right postero-lateral disc herniation with peridiscal osteophyte at the L4-L5 level indenting the extraforaminal segment of the right L4 nerve root.
3. Small, posterior peridiscal osteophytes at the L1-L2, L2-L3 and L3-L4 levels.