Date : 00.00.00
Name of the Patient : Abc Xyza Jalmn / F / 50 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE since 1 year.
Alleged H/O fall in February 0000.
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 D12-L1, L1-L2, L3-L4, L4-L5 and L5-S1 intervertebral discs.
There is minimal forward translation of the L5 vertebra over the S1 vertebra without obvious spondylolysis.
A small right far lateral (extraforaminal) disc herniation is noted at the L5-S1 level. Severe hypertrophic facetal arthropathy is noted at the L5-S1 level bilaterally.
A left paracentral disc herniation is seen at the L4-L5 level, indenting the traversing left L5 nerve root. The facet joints at this level show hypertrophic degenerative changes. A right far lateral (extraforaminal) disc bulge is noted at this level.
A small posterior disc bulge is noted at the L3-L4 level.
There is anterior wedging of the L1 vertebral body with fatty marrow changes. Herniation of the D12-L1 disc into the body of L1 is noted. Posterior disc bulges with peridiscal osteophytes are seen at the D12-L1 and L1-L2 levels.
Mild facetal hypertrophy is seen at the L3-L4 level.
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 L1 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 :
16.0 mm at L1-L2
18.0 mm at L2-L3
16.0 mm at L3-L4
10.0 mm at L4-L5
12.0 mm at L5-S1.
1. Minimal forward translation of the L5 vertebra over the S1 vertebra without obvious spondylolysis.
2. A small right far lateral (extraforaminal) disc herniation at the L5-S1 level with bilateral severe hypertrophic facetal arthropathy.
3. A left paracentral disc herniation at the L4-L5 level, indenting the traversing left L5 nerve root with hypertrophic facetal arthropathy at this level.
4. Anterior wedging of the L1 vertebral body with fatty marrow changes, may be the sequelae of previous trauma.