Date : 00.00.00
Name of the Patient : Abc Xyzi Chalmn / F / 45 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (right more than left) with paresthesias since 2 months.
H/O lifting heavy weights.
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 slight forward translation of the L2 over the L3 vertebral body without obvious spondylolysis.
There is a pseudoposterior disc herniation at the L2-L3 level with anterior indentation of the thecal sac and mild bilateral neural foraminal narrowing. The L2-L3 facet joints show hypertrophic degenerative changes.
Posterior disc herniation is noted at the L4-L5 level and a posterior peridiscal osteophyte is noted at the L5-S1 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L4-L5 facet joints bilaterally and the L5-S1 facet joint on the left show degenerative changes. Mild effusion is seen in the L5-S1 facet joint on the right side. Central and lateral canal stenosis is noted at the L4-L5 level.
Small posterior disc herniation is seen at the L3-L4 level. Anterior disc herniations are seen at the L4-L5 and L5-S1 levels. The L2-L3, L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content.
Posterior peridiscal osteophytes are noted in the lower lumbar levels.
The rest of the lumbar facet joints show mild degenerative changes.
Type I/III degenerative change is seen in the L5 and S1 vertebrae adjacent to the L5-S1 disc.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 :
13.0 mm at L1-L2
12.0 mm at L2-L3
15.0 mm at L3-L4
11.0 mm at L4-L5
11.0 mm at L5-S1.
The dorsal spine was screened with 4 mm thick T2 Weighted sagittal images and does not reveal any diagnostic feature of note.
- 3 - Scan-00002
1. Slight forward translation of the L2 over the L3 vertebral body without obvious spondylolysis.
2. A pseudoposterior disc herniation at the L2-L3 level with degenerative changes of the facet joints at this level.
3. Posterior disc herniation at the L4-L5 level and posterior peridiscal osteophyte at the L5-S1 level with degenerative changes of the L4-L5 facet joints bilaterally and on the left side at the L5-S1 level mild facetal effusion on the right side at the L5-S1 level.
4. Small posterior disc herniation at the L3-L4 level.
5. Tight canal at the L2-L3, L3-L4, L4-L5 and L5-S1 levels.