Date : 00.00.00
Name of the Patient : Abc Xyzndas Milmn / M / 76 yrs.
Referred by : Dr. Abc Xyzroff.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with radiating pain to BLE (right more than left).
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 appears to be partial sacralization of the L5 vertebra on the left side and the L5 vertebra is as marked on the film. Please correlate with plain radiographs.
There is scoliosis of the lumbar with convexity to the left side. Also seen is clockwise rotation of the lumbar vertebrae. There is left lateral subluxation of the L3 over the L4 vertebra.
The lumbar intervertebral discs show loss of water content. There is a decrease in the height of the L2-L3, L3-L4 and L4-L5 intervertebral discs with probable ankylosis of the L4-L5 disc. Hypointense areas on all the pulse sequences are noted within the L2-L3 and L3-L4 discs and this may represent calcium/vacuum phenomena.
A posterior disc herniation with peridiscal osteophytes is seen to indent the thecal sac and narrow both neural foramina at the L3-L4 level. The facet joints at this level show hypertrophic degenerative changes. Joint effusion is also noted within the left facet joint.
Posterior peridiscal osteophytes (hard disc) are seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level.
A right postero-lateral (foraminal) disc herniation is seen to narrow the right neural foramen at the L2-L3 level. A left postero-lateral (foraminal) disc protrusion is seen at the L1-L2 level.
The L2-L3 and L4-L5 facet joints show degenerative changes.
Far lateral (extraforaminal) disc herniations with peridiscal osteophytes are seen bilaterally at the L2-L3, L3-L4 and L4-L5 levels. Also seen are anterior disc herniations with peridiscal osteophytes at these levels.
A large Schmorls node is noted at the inferior aspect of the L3 vertebral body. Type II degenerative changes are noted in the lumbar vertebral bodies.
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 :
15.0 mm at L1-L2
15.0 mm at L2-L3
13.0 mm at L3-L4
15.0 mm at L4-L5
13.0 mm at L5-S1.
- 3 - Scan-00006
1. Scoliosis of the lumbar spine with convexity to the left side with left lateral subluxation of the L3 over the L4 vertebra.
2. Partial sacralization of the L5 vertebra on the left side. Please correlate with plain radiographs.
3. A posterior disc herniation with peridiscal osteophytes, hypertrophic facetal arthropathy and canal stenosis at the L3-L4 level with effusion within the left facet joint.
4. Posterior peridiscal osteophytes (hard discs) at the L4-L5 level.
5. A right postero-lateral (foraminal) disc herniation at the L2-L3 level.
6. Facetal arthropathy at the L2-L3 and L4-L5 levels.
7. Bilateral far lateral (extraforaminal) disc herniations with peridiscal osteophytes at the L2-L3, L3-L4 and L4-L5 levels.