Name of the Patient : Abc XyzBirlmn / M / 49 yrs.
Referred by : Dr. Abc Xyzrade.
Examination : M.R.I. of the Dorso-lumbo-sacral Spine.
CLINICAL PROFILE :
Alleged H/O fall 2 years back.
Now C/O backache with pain radiating to BLE.
EXAMINATION :
M.R.I. of the dorso-lumbo-sacral spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and T2 Weighted axial images.
OBSERVATION :
There is anterior wedging of the L1 and L2 vertebral bodies.
Schmorl's nodes are seen in the superior endplate of the L2 vertebral body.
There is mild posterior translation of the L4 over the L5 vertebra.
Postero-central and bilateral postero-lateral disc herniation with peridiscal osteophytes is noted at the L4-L5 level indenting the thecal sac anteriorly and narrowing both neural foramina. There is inferior migration of the disc. Facetal and ligamentum flavum hypertrophy is noted at this level with tight lumbar canal stenosis.
Small postero-central disc protrusion with peridiscal osteophytes is noted at the L5-S1 level indenting the thecal sac anteriorly.
Right far-lateral disc bulge is seen at the L4-L5 level.
Scan-00009
An anterior disc herniation with peridiscal osteophytes is noted at the L1-L2 level.
Facetal and ligamentum flavum hypertrophy is noted at the L4-L5 and L5-S1 levels. Facet joint effusion is noted at the L4-L5 level.
Type II degenerative (fatty) marrow changes are noted in the L2 vertebra. The rest of the lumbar vertebrae show spotty fatty marrow changes.
The rest of the visualized dorsal vertebral bodies and intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The visualized lower dorsal spinal cord reveals normal signal intensity.
The conus medullaris terminates at the L1-L2 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 :
14.0 mm at L1-L2
16.0 mm at L2-L3
14.0 mm at L3-L4
11.0 mm at L4-L5
11.0 mm at L5-S1.
IMPRESSION :
1. Anterior wedging of the L1 and L2 vertebral bodies.
2. Mild posterior translation of the L4 over the L5 and L5 over the S1 vertebra.
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- 3 - Scan-00009
3. Postero-central and bilateral postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level, with facetal and ligamentum flavum hypertrophy with tight lumbar canal.
4. Small postero-central disc protrusion with peridiscal osteophytes at the L5-S1 level.
5. Facetal and mild ligamentum flavum hypertrophy at the L4-L5 and L5-S1 levels.
Dr. Abc Xyzajan, M.D.
Clinical Assistant