Date : 00.00.00
Name of the Patient : Abc Xyzlal Dhollmn / M / 71 yrs.
Referred by : Dr. Abc Xyzolakia.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache 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 slight forward translation of the L5 over the S1 vertebral body with probable lysis of L5. Spina bifida of the L5 vertebra is noted.
Small pseudoposterior disc herniation is noted at the L5-S1 level with anterior indentation of the thecal sac. The L5-S1 facet joint on the right side shows degenerative changes.
A diffuse posterior disc bulge is seen at the L4-L5 level.
Small right far lateral disc bulge is noted at the L3-L4 level and a small posterior disc bulge is seen at the L2-L3 level. The lumbar intervertebral discs show loss of water content.
The lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1-L2 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 :
14.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
14.0 mm at L4-L5
13.0 mm at L5-S1.
1. Slight forward translation of the L5 over the S1 vertebral body with probable lysis at L5. Spina bifida of the L5 vertebra is noted.
2. Small pseudoposterior disc herniation at the L5-S1 level with hypertrophic facetal arthropathy on the right side.
3. A diffuse posterior disc bulge at the L4-L5 level.