Date : 00.00.00
Name of the Patient : Abc XyzBlmn / M / 75 yrs.
Referred by : Dr. Abc Xyzmdar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE since 5-6 months with burning sensation.
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 partial sacralization of the L5 vertebra and the L5 vertebra is as marked on the film.
There is reduction in height of the L4-L5 intervertebral disc and loss of water content of the lumbar intervertebral discs.
A posterior disc herniation with posterior peridiscal osteophytes is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing and indentation upon the foraminal portion of the L4 nerve roots. The thecal sac appears triangular in shape. The L4-L5 facet joints show degenerative changes, right more than left. Mild ligamentum flavum hypertrophy is noted at the L5 level.
A small posterior disc herniation with peridiscal osteophytes is seen at the L3-L4 level with bilateral far lateral disc bulges. A left far lateral disc bulge is noted at the L2-L3 level.
Anterior disc herniations with peridiscal osteophytes are seen at the D11-D12, D12-L1, L1-L2 and L2-L3 levels.
The lumbar facet joints show degenerative changes.
There is replacement of the normal marrow of the D11 and D12 vertebral bodies by hypointense areas on the T1 Weighted images which are seen to turn hyperintense on the T2 Weighted images. This may represent marrow edema/Type I degenerative changes.
Type II degenerative changes are noted in the L4 and L5 vertebrae adjacent to the L4-L5 intervertebral disc and the L3 vertebral body adjacent to the L2-L3 disc.
The rest of 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 S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
11.0 mm at L1-L2
10.0 mm at L2-L3
8.0 mm at L3-L4
6.0 mm at L4-L5
9.0 mm at L5-S1.
1. A posterior disc herniation with posterior peridiscal osteophytes at the L4-L5 level with indentation upon the foraminal portion of the L4 nerve roots with the L4-L5 facet joints showing degenerative changes, right more than left, with tight lumbar canal.
2. A small posterior disc herniation with peridiscal osteophytes at the L3-L4 level and bilateral far lateral disc bulges at this level.
3. Degenerative changes of the lumbar facet joints.