Date : 00.00.00
Name of the Patient : Abc Xyzlmn / F / 40 yrs.
Referred by : Dr. Abc Xyzaubal / Dr. Abc Xyzrel /
Dr. Abc Xyzdi.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache and neck pain with pain radiating to the LUE and LLE with weakness. Also C/O gait imbalance.
H/O kochs spine (low back) in 0000. Received AKT.
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 right. There is reduction in the height of the L2-L3 intervertebral disc with loss of water content of the lumbar intervertebral discs.
There is slight retroplacement of the L2 over the L3 vertebral body with a pseudo-posterior disc herniation with peridiscal osteophyte at the L2-L3 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L2-L3 facet joints show hypertrophic degenerative changes, right more than left.
Small left postero-lateral disc herniations are seen at the L3-L4 and the L4-L5 levels with left neural foraminal narrowing. The L3-L4 and L4-L5 facet joints on the left side show hypertrophic degenerative changes with resultant left lateral recess stenosis.
A small postero-central disc protrusion is seen at the L5-S1 level with anterior indentation of the thecal sac. The L5-S1 facet joints appear hypertrophied.
Mild ligamentum flavum hypertrophy is noted at the L4-L5 and L5 levels.
Type I degenerative change is seen in the L2 and L3 vertebral bodies adjacent to the L2-L3 intervertebral disc.
There is slight anterior wedging of the D11 and D12 vertebral bodies without any signal change.
The D12-L1 and L1-L2 facet joints show degenerative changes.
The rest of the lumbar vertebral bodies reveal normal signal intensity. 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 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
17.0 mm at L2-L3
15.0 mm at L3-L4
14.0 mm at L4-L5
12.0 mm at L5-S1.
The MRI features are suggestive of :
1. Scoliosis of the lumbar spine with convexity to the right.
- 3 - Scan-00006
2. Slight retroplacement of the L2 over the L3 vertebral body.
3. A pseudo-posterior disc herniation with peridiscal osteophyte at the L2-L3 level with hypertrophic facetal arthropathy.
4. Small left postero-lateral disc herniations at the L3-L4 and the L4-L5 levels with hypertrophic facetal arthropathy on the left side and resultant left lateral recess stenosis at these levels.
5. A small postero-central disc protrusion at the L5-S1 level with facetal hypertrophy at this level.
6. Mild ligamentum flavum hypertrophy at the L4-L5 and L5 levels.
7. Altered signal in the L2 and L3 vertebral bodies adjacent to the L2-L3 disc most likely represents Type I degenerative marrow changes.
8. Tight lumbar canal.