ke/hs/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyzben lmn / F / 66 yrs.
Referred by : Dr. Abc Xyznani.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE.
EXAMINATION :
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.
OBSERVATION :
The L2 vertebral body is as marked on the film. Please correlate with plain radiographs.
Small posterior and bilateral far lateral disc bulges are seen at the L3-L4, L4-L5 and L5-S1 levels.
A mild posterior disc bulge is noted at the L3-L4 level.
Small posterior peridiscal osteophytes are seen at the L3-L4, L4-L5 and L5-S1 levels.
The L3-L4 and L4-L5 discs height is reduced and the lumbar intervertebral discs show loss of water content.
Type II degenerative changes are noted in the L3, L4, L5 and S1 vertebral bodies.
The lumbar facet joints show degenerative changes. Mild ligamentum flavum hypertrophy is seen at the L3 and L5 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 D12-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 :
15.0 mm at L1-L2
15.0 mm at L2-L3
15.0 mm at L3-L4
13.0 mm at L4-L5
10.0 mm at L5-S1.
IMPRESSION :
The MRI features are suggestive of :
1. Small posterior and bilateral far lateral disc bulges at the L3-L4, L4-L5 and L5-S1 levels.
2. Facetal arthropathy in the lumbar region.
3. Mild ligamentum flavum hypertrophy at the L3 and L5 levels.