sb/hs/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyzai Dhalmn / F / 55 yrs.
Referred by : Dr. Abc Xyzvade.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE with paresthesias 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 loss of water content of the L3-L4, L4-L5 and L5-S1 intervertebral discs.
There is slight forward translation of the L4 over the L5 and L5 over the S1 vertebrae without obvious spondylolysis. Also seen is mild retroplacement of the L3 vertebra over the L4 vertebra.
A postero-central and right postero-lateral disc herniation is noted at the L5-S1 level with right neural foraminal narrowing.
A posterior disc herniation is noted at the L4-L5 level indenting the dural theca anteriorly and causing mild neural foraminal narrowing bilaterally.
A small posterior disc herniation is noted at the L3-L4 level.
The facet joints at the L4-L5 and L5-S1 levels show hypertrophic degenerative changes with joint effusion at the L4-L5 level.
Small posterior peridiscal osteophytes are noted at the L3-L4, L4-L5 and L5-S1 levels.
Type II degenerative marrow changes are noted adjacent to the L5-S1 disc.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
Incidentally noted is fat in the filum terminale over L1-L2 to L4-L5 levels.
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 :
11.0 mm at L1-L2
15.0 mm at L2-L3
14.0 mm at L3-L4
8.0 mm at L4-L5
5.0 mm at L5-S1.
Incidentally noted is fat in the filum terminale over L1-L2 to L4-L5 levels.
..3/.
- 3 - Scan-00000
IMPRESSION :
1. Slight forward translation of the L4 over the L5 and L5 over the S1 vertebrae without obvious spondylolysis (please correlate with plain radiographs).
2. A postero-central and right postero-lateral disc herniation at the L5-S1 level.
3. A posterior disc herniation at the L4-L5 level.
4. A small posterior disc herniation at the L3-L4 level.
5. Hypertrophic facetal arthropathy at the L4-L5 and L5-S1 levels with joint effusion at the L4-L5 level.
6. Tight lumbar canal at the L4-L5 and L5-S1 levels.