ke/bv/nl/rg.
Date : 00.00.00
Name of the Patient : Abc XyzR. Silmn / F / 61 yrs.
Referred by : Dr. Abc Xyz. Sangoi.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 6 months.
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 :
There is scoliosis of the lumbar spine with convexity to the left. There is reduction in height and loss of water content of the lumbar intervertebral discs.
There is lateral wedging of the L3 vertebra.
There are posterior disc bulges with peridiscal osteophytes at the L1-L2, L2-L3, L3-L4 and L4-L5 and L5-S1 levels with anterior indentation of the thecal sac and mild bilateral neural foraminal narrowing.
The L2-L3 facet joints on the right side show hypertrophic degenerative changes. The remaining lumbar facet joints show degenerative changes. Ligamentum flavum hypertrophy is seen at the L4 level.
Hypointense areas on the T1 Weighted images are seen to replace the normal marrow of the L2 and the L3 vertebral bodies adjacent to the disc which are seen to turn heterogeneously hyperintense on the T2 Weighted images and would represent Type I degenerative changes (edema).
..2/.
Diffuse fatty changes are noted in the lumbar vertebral bodies.
The rest of the facet joints and 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 :
20.0 mm at L1-L2
17.0 mm at L2-L3
18.0 mm at L3-L4
13.0 mm at L4-L5
12.0 mm at L5-S1.
IMPRESSION :
Gross degenerative changes in the lumbar spine with :
1. Scoliosis of the lumbar spine with convexity to the left.
2. Posterior disc bulges with peridiscal osteophytes at the L1-L2, L2-L3, L3-L4 and L4-L5 and L5-S1 levels.
3. Hypertrophic facetal arthropathy on the right side at the L2-L3 level and facetal hypertrophy in the lumbar region.
4. Fatty changes within the lumbar vertebrae suggesting osteoporosis.