Date : 00.00.00
Name of the Patient : Abc Xyzth D. Klmn / M / 52 yrs.
Referred by : Dr. Abc Xyzvade.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with tingling since 2 months.
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 normal lumbar lordosis and loss of water content of the L1-L2, L3-L4 and L5-S1 intervertebral discs.
Slight retroplacement of the L5 over the S1 vertebra is noted.
There is a fairly large, right paracentral extruded disc at the L5-S1 level indenting the traversing right S1 nerve root.
Small posterior disc bulges are noted at the L4-L5 and L3-L4 levels, narrowing the left neural foramen at the L4-L5 level and bilaterally at the L3-L4 level.
Facetal hypertrophy is noted in the lower lumbar region.
Focal fatty marrow changes are noted in the L4 vertebral body adjacent to the L3-L4 disc anteriorly.
- 2 - Scan-00005
There is slight anterior wedging of the L3 and D12 vertebral bodies without change in signal intensity.
Anterior peridiscal osteophytes are seen in the lumbar region.
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 L2 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 :
14.0 mm at L1-L2
15.0 mm at L2-L3
12.0 mm at L3-L4
13.0 mm at L4-L5
7.0 mm at L5-S1.
1. Slight retroplacement of the L5 over the S1 vertebra.
2. A fairly large, right paracentral extruded disc at the L5-S1 level indenting the traversing right S1 nerve root.
3. Posterior disc bulges at the L4-L5 and L3-L4 levels.
4. Facetal hypertrophy in the lower lumbar region.