Date : 00.00.00
Name of the Patient : Abc Xyza Zatlmn / F / 72 yrs.
Referred by : Dr. Abc Xyzcha.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias since 1 month.
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 all the lumbar intervertebral discs, except the L1-L2 disc.
A small, posterior and left far lateral disc bulge with peridiscal osteophytes is noted at the L5-S1 level with mild indentation upon the extraforaminal portion of the left L5 nerve root.
A posteriorly herniated disc with peridiscal osteophytes is noted at the L4-L5 level with bilateral neural foraminal narrowing. Mild ligamentum flavum hypertrophy is also seen at this level. The facet joints at the L4-L5 level show slight degenerative changes bilaterally with resultant canal stenosis.
Small posterior peridiscal osteophytes are at the L2-L3 and L3-L4 levels.
Anterior disc herniations with anterior peridiscal osteophytes are noted in the lumbar region.
The lumbar vertebral bodies show spotty fatty marrow changes. 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 :
15.0 mm at L1-L2
15.0 mm at L2-L3
15.0 mm at L3-L4
8.0 mm at L4-L5
11.0 mm at L5-S1.
1. A small, posterior and left far lateral disc bulge with peridiscal osteophytes at the L5-S1 level with mild indentation upon the extraforaminal portion of the left L5 nerve root.
2. A posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level with slight facetal arthropathy at this level and canal stenosis.
3. Small posterior peridiscal osteophytes at the L2-L3 and L3-L4 levels.