ke/sb/nl/nl
Date : 00.00.00
Name of the Patient : Abc Xyza Mlmn / F / 68 yrs.
Referred by : Dr. Abc XyzBhojraj.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (left more than right) with paresthesias since 7 years which has increased since 3-4 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 sacralization of the L5 vertebra and the L2 vertebral body is as marked on the film.
Small posterior disc bulge is seen at the L4-L5 level. The L4-L5 facet joints show degenerative changes bilaterally. Mild ligamentum flavum hypertrophy is also noted at this level.
The L5-S1 facet joints also show hypertrophic degenerative changes. The lumbar intervertebral discs except for the L5-S1 disc show loss of water content.
The lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L2 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 :
15.0 mm at L1-L2
17.0 mm at L2-L3
13.0 mm at L3-L4
11.0 mm at L4-L5
8.0 mm at L5-S1.
Screening, T2 Weighted sagittal images of the cervico-dorsal spine reveal minimal posterior peridiscal osteophytes in the mid cervical region. Facetal/ligamentum flavum hypertrophy is noted at the D3-D4 and D5-D6 levels.
IMPRESSION :
1. Sacralization of the L5 vertebra.
2. Small posterior disc bulge at the L4-L5 level with facetal arthropathy at this level.
3. Hypertrophic facetal arthropathy at the L5-S1 level.