Date : 00.00.00
Name of the Patient : Abc XyzQurlmn / M / 52 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache (on the right side) with discharging sinus. On AKT since 2 months.
H/O ? surgery done 2 months back. Details not available.
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 are small posterior disc bulges at the L4-L5 and L5-S1 levels with mild anterior indentation of the thecal sac at the L4-L5 level. The lumbar intervertebral discs show loss of water content.
The L4-L5 facet joints bilaterally show degenerative change.
Far lateral (extraforaminal) disc bulges are noted at the L2-L3 and L3-L4 levels on the left side and bilaterally at the L4-L5 and L5-S1 levels.
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 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 :
21.0 mm at L1-L2
19.0 mm at L2-L3
19.0 mm at L3-L4
17.0 mm at L4-L5
18.0 mm at L5-S1.
Fatty changes are noted in the visualized sacral and iliac bones bilaterally.
1. Small posterior disc bulges at the L4-L5 and L5-S1 levels.
2. Facetal arthropathy at the L4-L5 level.
3. Fatty changes in the visualized sacral and iliac bones bilaterally.