sb/ke/rg.
Date : 00.00.00
Name of the Patient : Abc Xyzabai M. Valmn / F / 70 yrs.
Referred by : Dr. Abc Xyzalani.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE with weakness.
EXAMINATION :
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.
OBSERVATION :
There is loss of water content of the lumbar intervertebral discs.
A small postero-central protruded disc is noted at the L5-S1 level. Slight facetal and ligamentum flavum hypertrophy is also noted at this level.
A posteriorly herniated disc is noted at the L4-L5 level with bilateral neural foraminal narrowing and impingement of the exiting L4 nerve roots in the neural foramen at the L4-L5 level bilaterally. There is also facetal and ligamentum flavum hypertrophy with resultant canal stenosis.
Left and right postero-lateral disc herniations with peridiscal osteophytes are noted at the L3-L4 level with bilateral neural foraminal narrowing.
A posteriorly bulging disc with peridiscal osteophytes is noted at the L2-L3 and L1-L2 levels.
A left paracentral peridiscal osteophytes is noted at the D12-L1 level.
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Bilateral far lateral disc bulges are noted over the L2-L3 to the L5-S1 levels.
Facetal hypertrophy is also noted at the L1-L2, L2-L3 and L3-L4 levels.
The lumbar vertebral bodies show spotty fatty marrow changes suggesting osteoporosis.
The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1-L2 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 :
10.0 mm at L1-L2
13.0 mm at L2-L3
13.0 mm at L3-L4
11.0 mm at L4-L5
11.0 mm at L5-S1.
Screening, T2 Weighted sagittal images of the dorsal region reveals slight facetal hypertrophy at the D9-D10 and D10-D11 levels. The visualized lower dorsal spinal cord shows normal signal intensity. There is no significant cord compression.
IMPRESSION :
1. A posteriorly herniated disc at the L4-L5 level with bilateral neural foraminal narrowing and impingement of the exiting L4 nerve roots in the neural foramen at the L4-L5 level bilaterally. There is also facetal and ligamentum flavum hypertrophy with resultant canal stenosis.
2. A small postero-central protruded disc at the L5-S1 level with slight facetal and ligamentum flavum hypertrophy at this level.
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3. Left and right postero-lateral disc herniations with peridiscal osteophytes at the L3-L4 level with bilateral neural foraminal narrowing.
4. A posteriorly bulging disc with peridiscal osteophytes at the L2-L3 and L1-L2 levels.
5. A left paracentral peridiscal osteophytes at the D12-L1 level.
6. Facetal hypertrophy at the L1-L2, L2-L3 and L3-L4 levels.
7. Lumbar canal stenosis.