hs/ke/rg/nl
Name of the Patient : Abc Xyzlmn / M / 54 yrs.
Referred by : Dr. Abc Xyz Sane.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE.
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 appears to be sacralization of the L5 vertebra and it is as marked on the film. Please correlate with plain radiographs.
There is mild retroplacement of the L3 over the L4 and L4 over the L5 vertebrae. The L3-L4 and L4-L5 intervertebral discs show loss of water content.
There is a posterior disc extrusion with peridiscal osteophytes indenting the thecal sac and narrowing both neural foramina at the L4-L5 level. There is also impingement of the traversing L5 nerve roots at this level.
There is a postero-central disc herniation, more to the right of the midline and indenting the thecal sac at the L3-L4 level, with right neural foraminal narrowing.
There is facetal hypertrophy with canal stenosis at the L4-L5 level. Mild facetal hypertrophy is noted at the L3-L4 level.
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There is an anterior disc herniation with peridiscal osteophytes at the L4-L5 level.
There is a hemangioma with fat content (hyperintense on all the pulse sequences) within the L1 vertebral body. Type II degenerative changes are seen within the L4 and L5 vertebral bodies adjacent to the L4-L5 intervertebral disc.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the 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 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
12.0 mm at L2-L3
15.0 mm at L3-L4
11.0 mm at L4-L5
11.0 mm at L5-S1.
IMPRESSION :
The MRI features are suggestive of :
1. Sacralization of the L5 vertebra and it is as marked on the film. Please correlate with plain radiographs.
2. A posterior disc extrusion with peridiscal osteophytes at the L4-L5 level with facetal hypertrophy and canal stenosis at this level.
3. A postero-central disc herniation, more to the right of the midline at the L3-L4 level.