Date : 00.00.00
Name of the Patient : Abc XyzSalalmn / F / 62 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with paresthesias since 2 years.
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. There is clockwise rotational anomaly of the upper lumbar vertebrae.
There is partial sacralization of the L5 vertebral body on the left side and slight forward translation of the L3 over the L4 vertebral body.
A diffuse posterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L4-L5 facet joints show degenerative changes.
A right postero-lateral disc herniation is noted at the L3-L4 level with right neural foraminal narrowing. The L3-L4 facet joints bilaterally, (right more than left) show degenerative changes.
A small right paracentral disc herniation with peridiscal osteophytes is seen at the L5-S1 level with anterior indentation of the thecal sac. Schmorls nodes are noted in the lumbar region. The lumbar intervertebral discs show loss of water content. There are Type II degenerative changes in the L4 and L5 vertebral bodies adjacent to the L4-L5 intervertebral disc.
The L1-L2 and L2-L3 facet joints on the right side and the L5-S1 facet joints on the left side show degenerative changes.
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 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 :
13.0 mm at L1-L2
14.0 mm at L2-L3
9.0 mm at L3-L4
12.0 mm at L4-L5
12.0 mm at L5-S1.
The MRI features are suggestive of :
1. Scoliosis of the lumbar spine with convexity to the left.
2. Partial sacralization of the L5 vertebral body on the left side with forward translation of the L3 over the L4 vertebra.
- 3 - Scan-00007
3. A diffuse posterior disc herniation at the L4-L5 level with facetal arthropathy.
4. A right postero-lateral disc herniation at the L3-L4 level.
5. A small right paracentral disc herniation with peridiscal osteophytes at the L5-S1 level.
6. Facetal arthropathy in the lumbar region.