Date : 00.00.00
Name of the Patient : Abc Xyzana Mlmn / F / 71 yrs.
Referred by : Dr. Abc Xyzrikh / Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias.
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 and reduction in height of the D12-L1, L1-L2 and L5-S1 intervertebral discs.
There is slight forward translation of the L4 over the L5 vertebra and slight retroplacement of the L3 over the L4 vertebra and L1 over the L2 vertebral body. Probable spondylolysis of the L3 vertebra is noted on the right (scans 102.6, 105.2).
A posterior and bilateral far lateral peridiscal osteophytes are noted at the L5-S1 level indenting the extraforaminal segments of the L5 nerve roots bilaterally.
Small posterior disc bulges are noted at the L2-L3, L3-L4 and L4-L5 levels. A posterior peridiscal osteophyte is noted at the L3-L4 level. Schmorls node is seen at the D12-L1 level.
Hypertrophic facetal arthropathy is noted at the L4-L5 level bilaterally and facetal hypertrophy is seen at the L3-L4 level and at the L1-L2 level on the right side.
Type II degenerative marrow changes are noted in the L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral 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-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 :
14.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
14.0 mm at L4-L5
12.0 mm at L5-S1.
1. Slight forward translation of the L4 over the L5 vertebra and slight retroplacement of the L3 over the L4 and L1 over the L2 vertebra with probable spondylolysis of the L3 vertebra on the right.
2. A posterior and bilateral far lateral peridiscal osteophytes at the L5-S1 level indenting the extraforaminal segments of the L5 nerve roots bilaterally.
3. Small posterior disc bulges at the L2-L3, L3-L4 and L4-L5 levels and a posterior peridiscal osteophyte at the L3-L4 level.
4. Hypertrophic facetal arthropathy at the L4-L5 level bilaterally and facetal hypertrophy at the L3-L4 level and at the L1-L2 level on the right side.