Date : 00.00.00
Name of the Patient : Abc Xyzen lmn / F / 70 yrs.
Referred by : Dr. Abc Xyzagwati.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with paresthesias and wasting of small muscles of feet since 6 months.
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 scoliosis of the lumbar spine with convexity to the left side and clockwise rotation of the upper lumbar vertebrae.
The lumbar intervertebral discs show loss of water content.
There is retrolisthesis of the L3 over the L4 vertebral body with a pseudo-posterior disc herniation at the L3-L4 level with mild anterior indentation of the thecal sac and bilateral neural foraminal narrowing and tight lumbar canal. The L3-L4 facet joints show slight degenerative changes.
Small posterior disc bulges are noted at the L4-L5 and L5-S1 levels with mild anterior indentation of the thecal sac. The facet joints at these levels on the left side show hypertrophic degenerative change.
A small left far lateral disc bulge is noted at the L2-L3 level. The L2-L3 facet joints on the right side show slight degenerative change.
Type III degenerative changes are seen in the L3 and L4 vertebral bodies adjacent to the L3-L4 intervertebral disc and Type II degenerative changes in the antero-superior portion of the L3 vertebral body.
Anterior peridiscal osteophytes are seen at the L3-L4 level.
Tarlovs cyst is seen at the S2 level bilaterally.
The rest of the lumbar vertebral bodies reveal spotty fatty marrow changes. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the 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 :
16.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
13.0 mm at L4-L5
8.0 mm at L5-S1.
The cervical spine was screened with the help of 5 mm thick T1 Weighted sagittal images which show reversal of normal cervical curvature and small posterior disc herniations at the C4-C5, C5-C6 and C6-C7 levels with small posterior peridiscal osteophytes. Fatty changes are noted in the cervical and upper dorsal vertebral bodies.
The dorsal spine was screened with the help of 4 mm thick T2 Weighted sagittal images which show a small posterior disc herniation at the D8-D9 level. The visualized dorsal intervertebral discs show loss of water content. Ligamentum flavum hypertrophy is seen over the D7-D8 to the D9-D10 levels.
- 3 - Scan-00002
1. Retrolisthesis of the L3 over the L4 vertebral body with a pseudo-posterior disc herniation at the L3-L4 level with tight lumbar canal.
2. Small posterior disc bulges at the L4-L5 and L5-S1 levels.
3. Facetal arthropathy at the L3-L4 level bilaterally and on the right side at the L2-L3 level and at the L4-L5 and L5-S1 levels on the left side.