Date : 00.00.00
Name of the Patient : Abc XyzKlmn / M / 65 yrs.
Referred by : Dr. Abc Xyzapadia.
Examination : M.R.I. of the Dorso-lumbar Spine.
CLINICAL PROFILE :
C/O backache since 2 months with weakness of BLE since 15 days.
M.R.I of the dorso-lumbar 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.
The lumbar intervertebral discs show loss of water content.
There is scoliosis of the lumbar spine wtih convexity to the right and anti-clockwise rotation of the L2, L3 and the L4 vertebral bodies. There is lateral subluxation of the L2 over the L3 and L3 over L4 vertebra.
There are diffuse posterior disc herniations with large peridiscal osteophytes at the L2-L3, L3-L4 and the L4-L5 levels with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. Anterior disc herniations with peridiscal osteophytes are also noted at this level. A large disc fragment is seen posterior to the L3 vertebra with impingement of the left L3 nerve root (scans 105.12, 104.12). Another disc fragment is seen in the right lateral recess of the L4 vertebra with impingement of the right L4 nerve root (scans 105.7, 104.7).
Small posterior and right far lateral disc bulge is seen at the L5-S1 level.
The L2, L3, L4 and the L5 vertebral bodies adjacent to the L2-L3, L3-L4 and L4-L5 intervertebral discs show Type I/Type III degenerative changes.
- 2 - Scan-00008
The right facet joint at the L4-L5 level shows hypertrophic degenerative changes.
The rest of the lumbar vertebral bodies reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12 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 :
15.0 mm at L1-L2
9.0 mm at L2-L3
7.0 mm at L3-L4
9.0 mm at L4-L5
12.0 mm at L5-S1.
The dorsal spine was screened with 5 mm thick T2 Weighted sagittal images which does not reveal any diagnostic feature of note.
The MRI features are suggestive of :
1. Scoliosis of the lumbar spine with convexity to the right.
2. A large posterior disc herniation with peridiscal osteophytes at the L2-L3 level with inferior migration of the disc posterior to L3 with impingement of the left L3 nerve root.
3. Diffuse posterior disc herniations with large peridiscal osteophytes at the L3-L4 and L4-L5 levels with a disc fragment seen in the right lateral recess of the L4 vertebra with impingement of the right L4 nerve root.