Date : 00.00.00
Name of the Patient : Abc Xyzi Merclmn / F / 59 yrs.
Referred by : Dr. Abc Xyzmpat.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE since 8-10 days.
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 a postero-central and right postero-lateral disc herniation indenting the thecal sac and the traversing right S1 nerve root at the L5-S1 level. There is right neural foraminal narrowing at this level.
There is a posterior disc herniation with peridiscal osteophytes indenting the thecal sac and narrowing both neural foramina (right more than left) at the L4-L5 level. Also seen is impingement of the exiting right L4 nerve root at this level. Bilateral far lateral (extraforaminal) disc herniations are noted at this level.
The L4-L5 and L5-S1 facet joints show hypertrophic degenerative changes. Ligamentum flavum hypertrophy is noted over the L3-L4 to the L5-S1 levels.
Posterior disc bulges are noted at the L2-L3 and L3-L4 levels. The facet joints at these levels show degenerative changes.
There are bilateral far lateral (extraforaminal) disc bulges at the L2-L3, L3-L4 and L5-S1 levels.
- 2 - scan-00007
Well-defined areas of hyperintensity on the all the pulse sequences are noted in the L4 vertebral body and would represent hemangiomas.
The lumbar intervertebral discs except at the L4-L5 level show loss of water content. The L4-L5 intervertebral disc is decreased in height.
The visualized lumbo-sacral vertebrae show areas of fatty replacement of normal marrow suggestive of osteoporotic changes. Hypointense areas are seen to involve the D11 vertebral body on the T1 Weighted images, the details of which are mentioned in the dorsal spine report.
Increased fat is noted in the renal medulla and sinus on the left side.
The conus medullaris terminates at the L1-L2 level and the thecal sac terminates at the S2 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
13.0 mm at L2-L3
12.0 mm at L3-L4
8.0 mm at L4-L5
9.0 mm at L5-S1.
1. A postero-central and right postero-lateral disc herniation at the L5-S1 level.
2. A posterior disc herniation with peridiscal osteophytes at the L4-L5 level.
- 3 - scan-00007
3. Bilateral far lateral (extraforaminal) disc bulges at the L2-L3, L3-L4 and L5-S1 levels.
4. Hypertrophic facetal arthropathy with canal stenosis at the L4-L5 and L5-S1 levels.
5. Posterior disc bulges with facetal arthropathy at the L2-L3 and L3-L4 levels.
6. Ligamentum flavum hypertrophy over the L3-L4 to the L5-S1 levels.
7. Osteoporotic changes in the visualized lumbo-sacral vertebrae.