Date : 00.00.00
Name of the Patient : Abc XyzMulmn / M / 76 yrs.
Referred by : Dr. Abc Xyznshi.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O radicular pain to the LLE since 15 days.
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. The L5-S1 intervertebral disc is reduced in height.
A posterior peridiscal osteophyte is noted at the L5-S1 level with bilateral neural foraminal narrowing and minimal indentation on the S1 nerve roots bilaterally. A small posterior disc herniation is also seen at this level.
A fairly large, postero-central extruded disc is noted at the L4-L5 level with thecal sac compression and bilateral neural foraminal narrowing.
Minimal posterior disc bulges are noted at the L1-L2, L2-L3 and L3-L4 levels.
The facet joints show hypertrophic degenerative changes at the L3-L4, L4-L5 and L5-S1 levels bilaterally, at the L1-L2 level on the left and on the right at the L2-L3 level.
Type II degenerative marrow changes are noted adjacent to the L5-S1 disc.
Mild ligamentum flavum hypertrophy is seen over the L4-L5 to the L5-S1 levels.
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 L2 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 :
16.0 mm at L1-L2
15.0 mm at L2-L3
14.0 mm at L3-L4
9.0 mm at L4-L5
12.0 mm at L5-S1.
1. A small posterior disc herniation with a
posterior peridiscal osteophyte at the L5-S1 level with bilateral neural foraminal narrowing and minimal indentation on the S1 nerve roots bilaterally.
2. A fairly large, postero-central extruded disc at the L4-L5 level with bilateral neural foraminal narrowing with canal stenosis at this level.
3. Hypertrophic facetal arthropathy at the L3-L4, L4-L5 and L5-S1 levels bilaterally at the L1-L2 level on the left and at the L2-L3 level on the right side.