Date : 00.00.00
Name of the Patient : Abc Xyzingh Gulmn / M / 75 yrs.
Referred by : Dr. Abc Xyzlkan / Dr. Abc Xyznghal.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (right more than left) since 2 years with paresthesias.
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 forward subluxation of the L4 over the L5 vertebra.
A small pseudoposterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L4-L5 facet joints show hypertrophic degenerative changes.
Small posterior disc bulge is seen at the L5-S1 level. The right facet joint at this level shows hypertrophic degenerative changes.
The lumbar intervertebral discs show loss of water content.
Type II degenerative changes are noted in the antero-superior portion of the L5 vertebra and antero-inferior portion of the L1 vertebra.
The rest of the lumbar vertebral bodies reveal normal signal intensity. The remaining 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 :
18.0 mm at L1-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
10.0 mm at L4-L5
13.0 mm at L5-S1.
1. Forward subluxation of the L4 over the L5 vertebra.
2. A small pseudoposterior disc herniation at the L4-L5 level with hypertrophic facetal arthropathy at this level.
3. Small posterior disc bulge at the L5-S1 level with hypertrophic degenerative changes of the right facet joint at this level.