hs/sb/nl/nl

Name of the Patient : Abc Xyz lmn / F / 60 yrs.
Referred by : Dr. Abc Xyzshar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with radiation of pain to BLE (right more than left).

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 and loss of normal lumbar lordosis.

The lumbar intervertebral discs show loss of water content. The lumbar vertebral bodies show areas of fatty replacement of normal marrow.

Type II degenerative changes are seen adjacent to the L2-L3 to L5-S1 intervertebral discs. Hypointense areas on all the pulse sequences within these intervertebral discs may represent calcium/vacuum phenomena.

There are posterior disc herniations with peridiscal osteophytes indenting the thecal sac and causing slight neural foraminal narrowing at the L2-L3, L3-L4, L4-L5 and L5-S1 levels. Anterior disc herniations with peridiscal osteophytes are noted over these levels. Also seen are bilateral far lateral disc herniations with peridiscal osteophytes over these levels.



A postero-central disc herniation is seen to indent the thecal sac at the L1-L2 level.

The L2-L3, L3-L4, L4-L5 and L5-S1 facet joints show degenerative changes.

There is atrophy of the psoas muscles and of the paraspinal muscles in the lumbo-sacral region.

The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12 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 :

11.0 mm at L1-L2
13.0 mm at L2-L3
12.0 mm at L3-L4
8.0 mm at L4-L5
9.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. Posterior disc herniations and bilateral far lateral disc herniations with facetal arthropathy at the L2-L3, L3-L4, L4-L5 and L5-S1 levels.

2. A postero-central disc herniation at the L1-L2 level.

3. Tight lumbar canal.

As compared to the previous MRI dated 00.00.00, there is no significant change.