Date : 00.00.00
Name of the Patient : Abc Xyzati Mlmn / F / 74 yrs.
Referred by : Dr. Abc Xyztrak / Dr. Abc Xyz. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (right more than left) with tingling in toes since several years which has increased since 5-6 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 loss of water content of the lumbar intervertebral discs.
The visualized dorso-lumbo-sacral vertebral bodies show spotty fatty marrow changes suggesting osteoporosis. The D10 vertebral body appears wedged.
There is slight retroplacement of the L1 vertebral body.
There is a right postero-lateral (foraminal) disc herniation at the L5-S1 level with right neural foraminal narrowing and mininal indentation on the traversing right S1 nerve root.
A postero-central disc herniation with peridiscal osteophytes is noted at the L3-L4 level with bilateral neural foraminal narrowing.
A small posterior disc bulge is noted at the L4-L5 level.
A small postero-central protruded disc is identified at the L2-L3 level.
Posterior peridiscal osteophytes are noted at the L1-L2 level with left neural foraminal narrowing.
The facet joints from the L2-L3 to the L5-S1 levels show hypertrophic degenerative changes. Slight ligamentum flavum hypertrophy is noted at the L3-L4 and L4-L5 levels.
Anterior disc herniations are noted in the upper lumbar region.
The rest of the facet joints and 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 :
14.0 mm at L1-L2
12.0 mm at L2-L3
7.0 mm at L3-L4
10.0 mm at L4-L5
12.0 mm at L5-S1.
- 3 - Scan-00000
1. Spotty fatty marrow changes in the visualized dorso-lumbo-sacral vertebrae suggests osteoporotic changes. Wedging of D10 vertebral body may be the sequelae of trauma superimposed on an osteoporotic spine.
2. A right postero-lateral (foraminal) disc herniation at the L5-S1 level with right neural foraminal narrowing and mininal indentation on the traversing right S1 nerve root.
3. A postero-central disc herniation with peridiscal osteophytes at the L3-L4 level.
4. Small posterior disc bulge at the L4-L5 level.
5. Small postero-central protruded disc at the L2-L3 level.
6. Posterior peridiscal osteophytes at the L1-L2 level.
7. Hypertrophic facetal arthropathy from the L2-L3 to the L5-S1 levels with slight ligamentum flavum hypertrophy at the L3-L4 and L4-L5 levels.
8. Canal stenosis at L3-L4 and L4-L5 levels.
As compared to the previous MRI dated 00.00.00 (scan no.0000), canal stenosis is noted at the L3-L4 and L4-L5 levels, probably to a greater degree at the L3-L4 level. Anterior wedging of the D10 vertebral body is identified on the present study (this vertebral body was not identified on the previous scan).