Date : 00.00.00
Name of the Patient : Abc Xyz Slmn / M / 70 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE since 6-7 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 water content of the lumbar intervertebral discs. Slight retroplacement of the L3 vertebra over the L4 vertebra is noted.
Posteriorly herniated discs with peridiscal osteophytes are noted at the L2-L3, L3-L4 and L4-L5 levels, with thecal sac compression and bilateral neural foraminal narrowing. The facet joints at these levels appear hypertrophied with resultant canal stenosis.
A small posterior disc herniation with bilateral neural foraminal narrowing is noted at the L5-S1 level. Facetal hypertrophy is noted at the L5-S1 level.
Bilateral far lateral (extraforaminal) disc herniations are noted over the L2-L3 to L5-S1 levels.
A small posterior disc bulge is noted at the L1-L2 level.
Type I and Type II degenerative marrow changes are noted adjacent to the L2-L3 disc. Type II degenerative changes are noted adjacent to nearly all the remaining lumbar intervertebral discs.
The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1 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
9.0 mm at L2-L3
12.0 mm at L3-L4
9.0 mm at L4-L5
11.0 mm at L5-S1.
1. Posteriorly herniated discs with peridiscal osteophytes at the L2-L3, L3-L4 and L4-L5 levels, with bilateral neural foraminal narrowing. Facetal hypertrophy is also noted over these levels with resultant canal stenosis.
2. A small posterior disc herniation with facetal hypertrophy at the L5-S1 level.
3. A small posterior disc bulge at the L1-L2 level.
4. Bilateral far lateral (extraforaminal) disc herniations over the L2-L3 to L5-S1 levels.