SB/KE/NL/RG.
Date : 00.00.00
Name of the Patient : Abc Xyz Khlmn / F / 69 yrs.
Referred by : Dr. Abc XyzChilwan.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE (left more than right) with paresthesias.
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.
There is minimal forward translation of the L4 over the L5 and L3 over the L4 vertebrae, without obvious spondylolysis.
Posterior and bilateral far lateral disc bulges are noted at the L3-L4, L4-L5 and L5-S1 levels. There is also bilateral facetal hypertrophy at these levels with ligamentum flavum hypertrophy at the L3-L4 and L4-L5 levels with resultant canal stenosis at the L3-L4 and L4-L5 levels.
Small left and right postero-lateral disc bulges are noted at the L1-L2 and L2-L3 levels with facetal and ligamentum flavum hypertrophy at these levels.
The lumbar vertebral bodies show spotty fatty marrow changes. 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 :
12.0 mm at L1-L2
9.0 mm at L2-L3
7.0 mm at L3-L4
8.0 mm at L4-L5
12.0 mm at L5-S1.
IMPRESSION :
1. Minimal forward translation of the L4 over the L5 and L3 over the L4 vertebrae, without obvious spondylolysis.
2. Posterior and bilateral far lateral disc bulges at the L3-L4, L4-L5 and L5-S1 levels with bilateral facetal hypertrophy at these levels.
3. Ligamentum flavum hypertrophy at the L3-L4 and L4-L5 levels with resultant canal stenosis at these levels.
4. Small left and right postero-lateral disc bulges at the L1-L2 and L2-L3 levels with facetal and ligamentum flavum hypertrophy with tight canal at these levels.