sb/ke
Date : 00.00.00

Name of the Patient : Abc Xyzkumar Plmn / M / 46 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE with paresthesias since 5 years which has increased since 1 month.
H/O Kochs lesion at L3 level 5 years back for which patient received AKT.

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 reduction in height of the L2-L3 intervertebral disc and loss of water content of L2-L3, L3-L4 and L5-S1 intervertebral discs.

Fatty marrow changes are noted in the L2 and L3 vertebral bodies adjacent to the L2-L3 intervertebral disc. Slight irregularity of the inferior cortical endplate of L2 and superior cortical endplate of L3 is noted. Anterior and posterior peridiscal osteophytes are seen at the L2-L3 level.

There are small posterior and bilateral far lateral disc bulges with peridiscal osteophytes at the L5-S1 level.

A small postero-central protruded disc is noted at the L4-L5 level.

- 2 - Scan-00000


Type II degenerative marrow changes are noted adjacent to the L5-S1 intervertebral disc.

The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints and 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 :

19.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
13.0 mm at L4-L5
15.0 mm at L5-S1.

IMPRESSION :

1. Reduction in height of the L2-L3 disc with fatty marrow changes in the L2 and L3 vertebral bodies as described and irregularity of the cortical endplates adjacent to the L2-L3 disc may be the sequelae of previous osteitis with discitis, in the given clinical setting (no previous radiological investigations were available for review/comparison).

2. Small posterior and bilateral far lateral disc bulge with peridiscal osteophyte at the L5-S1 level.

3. A small postero-central protruded disc at the L4-L5 level.