sb/bv/nl/rg.
/779 Date : 21/00.00.00

Name of the Patient : Abc Xyz M. lmn / M / 65 yrs.
Referred by : Dr. Abc Xyzthak.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias since 1 1/2 months.
C/O urgency in passing urine.

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 lumbo-sacral spine with convexity to the left.

Severe degenerative changes are seen within the lumbar spine.

There is loss of normal lumbar lordosis and loss of water content of the lumbar intervertebral discs.

The lumbar intervertebral discs are reduced in height.

There is a posterior and bilateral far lateral disc bulge at the L5-S1 level, with bilateral neural foraminal narrowing. Facetal and ligamentum flavum hypertrophy is noted.

There is a posteriorly herniated disc at the L4-L5 level with thecal sac compression and bilateral neural foraminal narrowing. Bilateral far lateral disc herniations are noted. There is facetal and ligamentum flavum hypertrophy with canal stenosis. Similar changes are noted at L3-L4 level.
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Posterior disc bulges with peridiscal osteophytes are noted at the L1-L2 and L2-L3 levels with bilateral neural foraminal narrowing. Facetal hypertrophy is also noted at these levels.

Small posterior disc bulges with peridiscal osteophytes are noted in the lower dorsal region with facetal hypertrophy at the D11-D12 level.

Anterior disc herniations with anterior peridiscal osteophytes are noted in the lumbar region.

Type II degenerative marrow changes are noted adjacent to the L4-L5 and L5-S1 discs and Type III degenerative marrow changes are noted adjacent to the L3-L4 disc. The L3-L4 disc shows evidence of calcium/vacuum phenomena.

The rest of the lumbar vertebral bodies show spotty fatty marrow changes. The visualized pre and paravertebral 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 :

10.0 mm at L1-L2
11.0 mm at L2-L3
9.0 mm at L3-L4
10.0 mm at L4-L5
11.0 mm at L5-S1.
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- 3 - SCan-00009


IMPRESSION :

The MRI features are suggestive of severe degenerative changes in the lumbar spine with scoliosis of the lumbar spine with convexity to the left side with,

1. Posteriorly herniated discs with bilateral far lateral disc herniations at the L3-L4 and L4-L5 levels with facetal and ligamentum flavum hypertrophy.

2. Posterior disc bulges with peridiscal osteophytes at the L1-L2 and L2-L3 levels and facetal hypertrophy at these levels.

3. Small posterior disc bulges with peridiscal osteophytes in the lower dorsal region with facetal hypertrophy at the D11-D12 level.

4. Lumbar canal stenosis over the L3-L4 and L4-L5 levels with tight lumbar canal over the L1-L2, L2-L3 and L5-S1 levels.