sb/bv/rg/nl
Name of the Patient : Abc Xyzdevi Vlmn / F / 50 yrs.
Referred by : Dr. Abc Xyzah / Dr. Abc Xyznavati.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE with paresthesias since 2 months.
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 vertebra without obvious spondylolysis. A pseudo-posterior disc herniation is noted at the L4-L5 level indenting the dural theca anteriorly. There is also facetal hypertrophy at the L4-L5 level bilaterally with right sided facet joint effusion.
A minimal postero-central protruded disc is noted at the L3-L4 level.
There is an increase in the epidural fat at the L5-S1 and S1 levels suggesting epidural lipomatosis in that region.
The lumbar vertebral bodies reveal normal signal intensity. The rest of the facet joints in the lumbar region appear hypertrophied. The visualized pre and paravertebral soft tissues are unremarkable.
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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 :
19.0 mm at L1-L2
19.0 mm at L2-L3
18.0 mm at L3-L4
11.0 mm at L4-L5
12.0 mm at L5-S1.
Screening T1 Weighted sagittal images of the cervico-dorsal region do not reveal any significant feature of note.
IMPRESSION :
1. Minimal forward translation of the L4 over the L5 vertebra without obvious spondylolysis.
2. A pseudo-posterior disc herniation at the L4-L5 level with bilateral facetal hypertrophy and right sided facet joint effusion at that level.