/6 Date : 00.00.00
Name of the Patient : Abc Xyznisa Hulmn / F / 61 yrs.
Referred by : Dr. Abc Xyzpadia.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 1 year.
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.
The pelvis was screened with 5 mm thick T2 Weighted (with fat saturation) axial images.
There is mild retroplacement of the L3 over the L4 and the L4 over the L5 vertebrae.
A posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level.
There are posterior disc bulges at the L3-L4 and L5-S1 levels.
Left postero-lateral and left far lateral disc protrusions are seen to narrow the left neural foramen and indent the exiting left L5 nerve root at the L5-S1 level. A right far lateral (extraforaminal) disc bulge is noted at the L3-L4 level.
The facet joints bilaterally at the L5-S1 level and on the left side at the L4-L5 level show hypertrophic degenerative changes. Facetal hypertrophy is seen bilaterally at the L2-L3 and L3-L4 levels and on the right side at the L4-L5 level.
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The lumbar intervertebral discs show loss of water content.
Anterior disc herniations with peridiscal osteophytes are noted at the L2-L3 and L3-L4 levels. Few of the lumbar vertebral bodies show areas of fatty replacement of normal marrow.
The visualized pre and paravertebral soft tissues are unremarkable.
There is evidence of an area of hyperintensity on the T2 Weighted images in the right adnexal region and this may represent a bowel loop/cystic lesion (further evaluation would be worthwhile).
The conus medullaris terminates at the 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 :
14.0 mm at L1-L2
15.0 mm at L2-L3
13.0 mm at L3-L4
10.0 mm at L4-L5
9.0 mm at L5-S1.
The MRI features are suggestive of :
1. A posterior disc herniation with canal stenosis
at the L4-L5 level.
2. Posterior disc bulges at the L3-L4 and L5-S1 levels with a tight canal at the L5-S1 level.
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3. Left postero-lateral and left far lateral disc protrusions at the L5-S1 level.
4. Hypertrophic facetal arthropathy bilaterally at the L5-S1 level and on the left side at the L4-L5 level.
5. Facetal hypertrophy bilaterally at the L2-L3 and L3-L4 levels and on the right side at the L4-L5 level.