Date : 00.00.00
Name of the Patient : Abc Xyzen L. lmn / F / 61 yrs.
Referred by : Dr. Abc Xyzngoi.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE (right more than left) since 15-20 days.
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.
There is sacralization of the L5 vertebra and the L1 vertebral body is as marked on the film.
There is loss of water content of the L2-L3, L3-L4 and L4-L5 intervertebral discs.
There is a posterior and left far lateral disc bulge at the L4-L5 level with slight bilateral neural foraminal narrowing. Facetal and ligamentum flavum hypertrophy is noted at this level. Probable indentation on the extraforaminal left L4 nerve root is visualized.
A small posterior disc herniation with peridiscal osteophytes is noted at the L3-L4 level with bilateral neural foraminal narrowing. There is also facetal and ligamentum flavum hypertrophy and resultant canal stenosis at this level.
A Schmorls node is noted along the superior cortical endplate of L3. Anterior disc herniation is seen at the L3-L4 level.
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.
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 :
17.0 mm at L1-L2
14.0 mm at L2-L3
8.0 mm at L3-L4
13.0 mm at L4-L5
8.0 mm at L5-S1.
1. Sacralization of the L5 vertebra.
2. A posterior disc herniation with peridiscal osteophytes at the L3-L4 level with facetal and ligamentum flavum hypertrophy and resultant canal stenosis at this level.
3. A posterior and left far lateral disc bulge at the L4-L5 level with facetal hypertrophy and tight lumbar canal at this level.