sb/bv/nl/rg.
Name of the Patient : Abc XyzBhlmn / F / 52 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O pain in the right hip region with tingling since 2 months.
H/O poliomyelitis in right leg.
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 scoliosis of the lumbar spine with convexity to the right with anti-clockwise rotation of the lumbar vertebrae.
There is loss of water content of the L4-L5 and L5-S1 intervertebral discs with the L4-L5 disc appearing reduced in height.
There is a minimal, posterior disc bulge at the L5-S1 level.
There is a right postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with slight inferior migration of the disc fragment indenting the traversing right L5 nerve root. Slight right neural foraminal narrowing is noted.
Facetal hypertrophy is noted in the lumbar region, more at the L4-L5 and L5-S1 levels.
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There is atrophy of the left psoas muscle and the muscles in the left paraspinal region with fatty replacement in these regions.
Type II degenerative marrow changes are noted adjacent to the L4-L5 and L5-S1 intervertebral disc.
Schmorls node is seen in the superior aspect of the L5 vertebra.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The visualized prevertebral 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 :
19.0 mm at L1-L2
18.0 mm at L2-L3
18.0 mm at L3-L4
16.0 mm at L4-L5
17.0 mm at L5-S1.
IMPRESSION :
1. Scoliosis of the lumbar spine with convexity to the right.
2. A right postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with slight inferior migration of the disc fragment indenting the traversing
right L5 nerve root.
3. Facetal hypertrophy in the lumbar region, more at the L4-L5 and L5-S1 levels.
4. Atrophy of the left psoas muscle and the muscles in the left paraspinal region with fatty replacement in these regions which may be the sequelae of previous poliomyelitis.