sb/ke/rg/nl
Name of the Patient : Abc XyzPlmn / M / 71 yrs.
Referred by : Dr. Abc Xyznghal
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE with paresthesias since 2 years.
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 all the lumbar intervertebral discs except the L5-S1 intervertebral disc.
There is a small posterior disc bulge at the L5-S1 level with hypertrophic facetal arthropathy at this level.
There is a posteriorly herniated disc at the L4-L5 level with bilateral neural foraminal narrowing. There is also hypertrophic facetal arthropathy and ligamentum flavum hypertrophy with canal stenosis at this level.
A minimal posterior disc bulge is noted at the L1-L2 and L3-L4 levels. Bilateral far lateral disc bulges are seen at the L3-L4 and L4-L5 levels.
Type II degenerative change is seen in the L5 vertebral body adjacent to the L4-L5 intervertebral disc.
Scan-00006
The rest of the lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints and 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 :
15.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
12.0 mm at L4-L5
10.0 mm at L5-S1.
IMPRESSION :
1. A small posterior disc bulge at the L5-S1 level with hypertrophic facetal arthropathy at this level.
2. A posteriorly herniated disc at the L4-L5 level with hypertrophic facetal arthropathy and ligamentum flavum hypertrophy with canal stenosis at this level.