Date : 00.00.00
Name of the Patient : Abc Xyz Gonsalmn / M / 65 yrs.
Referred by : Dr. Abc Xyzar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with radiating pain to BLE and 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 loss of water content of the lumbar intervertebral discs. Slight retroplacement of the L3 over the L4 and L4 over the L5 vertebrae is noted.
Posteriorly herniated discs with peridiscal osteophytes are noted at the L4-L5 and L3-L4 levels with bilateral neural foraminal narrowing. Slight inferior migration of the disc fragment is noted at the L3-L4 level. There is also facetal hypertrophy at these levels, with resultant canal stenosis.
A small posterior disc herniation with peridiscal osteophytes is noted at the L2-L3 level.
A minimal posterior disc bulge is noted at the L1-L2 level.
Bilateral far lateral disc bulges are seen at the L2-L3 and L3-L4 levels.
Slight facetal hypertrophy is also noted at the L5-S1 level.
Focal fatty marrow changes are seen in the lumbar region, with Schmorls nodes in the upper and mid lumbar regions.
A probable, right sided conjoint L5 and S1 nerve root is noted.
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 :
13.0 mm at L1-L2
12.0 mm at L2-L3
9.0 mm at L3-L4
11.0 mm at L4-L5
12.0 mm at L5-S1.
1. Posteriorly herniated discs with peridiscal osteophytes at the L4-L5 and L3-L4 levels with bilateral neural foraminal narrowing. Slight inferior migration of the disc fragment is noted at the L3-L4 level. Facetal hypertrophy is seen at these levels with resultant canal stenosis.
2. A small posterior disc herniation with peridiscal osteophytes at the L2-L3 level.
3. Slight facetal hypertrophy at the L5-S1 level.
4. A probable, right sided conjoint L5 and S1 nerve root.