Scan No :00001 Date : 00.00.00
Name of the Patient : Abc Xyzilaben N.Zalmn / F / 69 yrs
Referred by : Dr. Abc Xyzra.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with numbness since 10 days.
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 scoliosis of the lumbar spine with convexity to the left. Resultant clockwise rotation of the upper lumbar vertebrae is identified.
There is anterior wedging of the L2 vertebral body.
Posterior disc herniations with peridiscal osteophytes is seen to indent the thecal sac at the L2-L3 and L4-L5 levels.
Posterior disc bulges with small peridiscal osteophytes are noted at the L3-L4 and L5-S1 levels. Bilateral far lateral (extraforaminal) disc bulges are seen at the L2-L3, L4-L5 and L5-S1 levels.
The L4-L5 and L5-S1 facet joints on the left side shows severe hypertrophic degenerative changes. The facet joints at the L4-L5 and L5-S1 levels on the right side and bilaterally at the L3-L4 level show hypertrophic degenerative changes. Facetal hypertrophy is seen at the L2-L3 level.
There is severe ligamentum flavum hypertrophy at the L4-L5 and L5 levels.
Type II degenerative changes are noted in the L2, L4 and L5 vertebral bodies. The lumbar vertebral bodies show areas of fatty replacement suggesting osteoporotic changes.
The lumbar intervertebral discs show loss of water content.
The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the 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 :
15.0 mm at L1-L2
14.0 mm at L2-L3
15.0 mm at L3-L4
13.0 mm at L4-L5
14.0 mm at L5-S1.
The MRI features are suggestive of :
1. Posterior disc herniations with peridiscal osteophytes at the L2-L3 and L4-L5 levels.
2. Severe hypertrophic facetal arthropathy at the L4-L5 and L5-S1 levels on the left side.
3. Hypertrophic facetal arthropathy at the L4-L5 and L5-S1 levels on the right side and bilaterally at the L3-L4 level.
4. Canal stenosis at the L4-L5 level with tight canal at the L2-L3 level.