Date : 00.00.00
Name of the Patient : Abc Xyznnisa Ghalmn / F / 58 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE since 4-6 months.
H/O tuberculosis in the left kidney 18 years back for which patient was operated. Received AKT.
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 T2 Weighted axial images.
S. I. joints were scanned with 5 mm thick T1 Weighted axial images and 4 mm thick T1 Weighted and STIR coronal images.
There is loss of water content of the lumbar intervertebral discs. There is minimal forward translation of the L4 over the L5 vertebra without obvious spondylolysis.
A small posterior disc bulge is noted at the L4-L5 level.
A small postero-central protruded disc with peridiscal osteophyte is noted at the L5-S1 level.
The facet joints at the L3-L4, L4-L5 and L5-S1 levels show hypertrophic degenerative changes (maximum at the L4-L5 level).
Fatty marrow changes are noted in the L5 vertebral body.
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-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 :
17.0 mm at L1-L2
16.0 mm at L2-L3
18.0 mm at L3-L4
13.0 mm at L4-L5
12.0 mm at L5-S1.
The study of the sacro-iliac joints reveal widening of the sacro-iliac joint space bilaterally with marginal osteophytes along the anterior margins of the sacro-iliac joints on either sides. Irregularity of the margins of the sacro-iliac joints is also noted, with periarticular sclerotic changes. No obvious bone destruction or soft tissue mass lesion is identified.
1. Minimal forward translation of the L4 over the L5 vertebra without obvious spondylolysis.
2. A small posterior disc bulge at the L4-L5 level.
3. A small postero-central protruded disc with peridiscal osteophyte at the L5-S1 level.
4. Hypertrophic facetal arthropathy at the L3-L4, L4-L5 and L5-S1 levels (maximum at the L4-L5 level).
5. Changes in the sacro-iliac joints on either side may be the result of osteitis condensans ilii (? degenerative).