Date : 00.00.00
Name of the Patient : Abc Xyz Almn / M / 42 yrs.
Referred by : Dr. Abc Xyzsari.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 3-4 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 scoliosis of the lumbar spine with convexity to the left. Lateral wedging of L2 vertebral body on right with lateral subluxation of the L2 vertebral body to the left is noted. Slight clockwise rotational anomaly of the L1, L2 and L3 vertebrae is noted. The thecal sac is hence identified more to the right of the midline over these levels.
There is loss of water content of the lumbar intervertebral discs.
Generalized, small, posterior and bilateral far lateral disc bulges are noted at the L3-L4 and L4-L5 levels.
Right postero-lateral and right far lateral disc bulges with peridiscal osteophytes are noted at the L1-L2 and L2-L3 levels.
The facet joints at the L1-L2, L2-L3 and L5-S1 levels show slight degenerative changes bilaterally.
Type II degenerative marrow changes are noted adjacent to the L1-L2 disc and Type I degenerative marrow changes are noted adjacent to the L2-L3 disc. A hemangioma with fat content is noted in the L3 vertebral body.
The rest of the lumbar vertebral bodies reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1-L2 level and the thecal sac terminates at the S1-S2 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
16.0 mm at L2-L3
20.0 mm at L3-L4
18.0 mm at L4-L5
17.0 mm at L5-S1.
1. Scoliosis of the lumbar spine with convexity to the left with lateral wedging of the L2 body on the right and lateral subluxation of the L2 vertebral body to the left is noted.
2. Right postero-lateral and right far lateral disc bulges with peridiscal osteophytes at the L1-L2 and L2-L3 levels.
3. Slight degenerative changes of the facet joints at the L1-L2, L2-L3 and L5-S1 levels, bilaterally.