sb/hs/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyzana Galmn / F / 69 yrs.
Referred by : Dr. Abc Xyz. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE since 4-5 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 lumbar intervertebral discs.
There is a posteriorly bulging disc at the L4-L5 level with a small left postero-lateral disc herniation narrowing the left neural foramen and indenting the exiting left L4 and traversing left L5 nerve roots. There is also facetal and ligamentum flavum hypertrophy and a resultant tight lumbar canal at this level.
Slight facetal arthropathy is noted at the L5-S1 level.
Fatty marrow changes are noted in the L2 vertebral body.
The rest of the lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
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The conus medullaris terminates at the L1-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 :
17.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
10.0 mm at L4-L5
10.0 mm at L5-S1.
IMPRESSION :
1. A posteriorly bulging disc at the L4-L5 level with a small left postero-lateral disc herniation narrowing the left neural foramen and indenting the exiting left L4 and traversing left L5 nerve roots. There is also facetal and ligamentum flavum hypertrophy and a resultant tight lumbar canal at that level.
2. Slight facetal arthropathy at the L5-S1 level.