sb/ke/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzand Blmn / M / 65 yrs.
Referred by : Dr. Abc XyzJ. Dadia.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias since 2 years.

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.

There is loss of water content of the upper lumbar intervertebral discs.

A posteriorly bulging disc is noted at the L4-L5 level with slight bilateral neural foraminal narrowing. Facetal and ligamentum flavum hypertrophy is also noted with resultant canal stenosis.

Facetal hypertrophy is seen at the L3-L4 and L5-S1 levels.

The lumbar vertebral bodies shows spotty fatty marrow changes.

The visualized pre and paravertebral soft tissues are unremarkable.




The conus medullaris terminates at the 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 :

15.0 mm at L1-L2
14.0 mm at L2-L3
13.0 mm at L3-L4
12.0 mm at L4-L5
14.0 mm at L5-S1.

Screening of the cervico-dorsal and dorsal spines reveals cerebellar tonsillar ectopia with a syrinx extending from the C1-C2 level upto about D7 vertebral level. Scoliotic deformity of the upper dorsal spine is also noted with convexity to the left.

IMPRESSION :

1. Sacralization of the L5 vertebra.

2. A posteriorly bulging disc at the L4-L5 level with facetal and ligamentum flavum hypertrophy with resultant canal stenosis.

3. Facetal hypertrophy at the L3-L4 and L5-S1 levels.

4. Cerebellar tonsillar ectopia with a syrinx extending from the C1-C2 level upto about the D7 vertebral level.

5. Scoliotic deformity of the upper dorsal spine with convexity to the left.