Date : 00.00.00
Name of the Patient : Abc Xyzai Badlmn / M / 64 yrs.
Referred by : Dr. Abc Xyznghal.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with tingling since 1 1/2 - 2 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 minimal forward translation of the L4 over the L5 vertebra, without obvious spondylolysis.
There is loss of water content of the lumbar intervertebral discs.
There is a small posterior disc herniation at the L4-L5 level indenting the dural theca anteriorly. Hypertrophic facetal arthropathy and ligamentum flavum hypertrophy is also noted at this level with canal stenosis.
A minimal posterior disc bulge is noted at the L3-L4 level.
Right far lateral peridiscal osteophytes are noted at the D12-L1 and L1-L2 levels.
The lumbar vertebral bodies reveal normal signal intensity. 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
13.0 mm at L3-L4
10.0 mm at L4-L5
9.0 mm at L5-S1.
Screening, T2 Weighted sagittal images of the dorsal spine reveal anterior peridiscal osteophytes, more to the right of the midline in the mid and lower dorsal region. The visualized dorsal spinal cord shows normal signal.
1. Minimal forward translation of the L4 over the L5 vertebra, without obvious spondylolysis.
2. A small posterior disc herniation at the L4-L5 level with hypertrophic facetal arthropathy and ligamentum flavum hypertrophy and canal stenosis.
3. Right far lateral peridiscal osteophytes at the D12-L1 and L1-L2 levels.