Date : 00.00.00
Name of the Patient : Abc Xyz Almn / M / 32 yrs.
Referred by : Dr. Abc Xyz. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE (right more than left) since 7 years.
Alleged H/O jump from a height prior to this.
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 L1-L2, L2-L3 and L3-L4 intervertebral discs. There is mild retroplacement of the L2 vertebra over the L3 vertebra.
Posteriorly bulging discs are noted at the L4-L5 and L5-S1 levels with bilateral facetal hypertrophy and canal stenosis.
Small posterior disc bulge is seen at the L3-L4 level.
A small postero-central disc herniation with peridiscal osteophytes is noted at the L2-L3 level, indenting the dural theca anteriorly.
Minimal anterior wedging of the L4 vertebral body is noted.
Type II degenerative marrow changes are noted adjacent to the superior cortical endplates of the L3 and L4 vertebral bodies.
The pedicles of the lower lumbar vertebrae appear congenitally short in their antero-posterior dimensions.
The rest of 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 :
14.0 mm at L1-L2
9.0 mm at L2-L3
9.0 mm at L3-L4
7.0 mm at L4-L5
7.0 mm at L5-S1.
Incidentally noted is an ectopic right kidney.
1. Posteriorly bulging discs at the L4-L5 and L5-S1 levels with bilateral facetal hypertrophy.
2. A small posterior disc bulge with a tight canal at the L3-L4 level.
3. A small postero-central disc herniation with peridiscal osteophytes with a tight canal at the L2-L3 level.
4. Congenitally short pedicles of the lower lumbar vertebrae in their antero-posterior dimensions with canal stenosis at the L4-L5 and L5-S1 levels.
5. Ectopic right kidney.