sb/ke
Date : 00.00.00
Name of the Patient : Abc Xyz Slmn / F / 50 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Dorso-lumbar Spine.
CLINICAL PROFILE :
C/O numbness from knee downwards in BLE since 2 months.
H/O fever prior to this.
EXAMINATION :
M.R.I of the dorso-lumbar 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 left.
There is slight loss of water content of the L4-L5 intervertebral disc.
A posteriorly herniated disc is noted at the L4-L5 level indenting the dural theca anteriorly. A right postero-lateral and far lateral disc herniation is also noted at this level with right neural foraminal narrowing and indenting the extraforaminal segment of the right L4 nerve root.
A minimal posterior disc bulge is seen at the L3-L4 level.
Left far lateral peridiscal osteophytes are noted at the L2-L3 and L1-L2 levels.
Slight facetal arthropathy is noted at the L4-L5 and L5-S1 levels, more on the right side.
The visualized dorso-lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The visualized lower dorsal spinal cord shows 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 :
15.0 mm at L1-L2
15.0 mm at L2-L3
14.0 mm at L3-L4
10.0 mm at L4-L5
12.0 mm at L5-S1.
The cervical and dorsal spines were screened with 5 mm thick T2 Weighted sagittal images and do not reveal any significant feature of note.
IMPRESSION :
1. Scoliosis of the lumbar spine with convexity to the left.
2. A posteriorly herniated disc with a right postero-lateral and far lateral disc herniation at the L4-L5 level indenting the extraforaminal segment of the right L4 nerve root.
3. Left far lateral peridiscal osteophytes at the L2-L3 and L1-L2 levels.
4. Slight facetal arthropathy at the L4-L5 and L5-S1 levels, more on the right side.