sb/hs/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyza Siddlmn / F / 33 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE (right more than left) with paresthesias since 1 month.
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 loss of water content of the lower dorsal, L1-L2, L2-L3 and L5-S1 intervertebral discs.
There is Grade I spondylolisthesis of the L5 vertebra over the S1 vertebra with spondylolysis at the L5 level bilaterally. A resultant posterior disc bulge with a peridiscal osteophyte is noted at the L5-S1 level, minimally indenting the dural theca anteriorly.
There is mild retroplacement of the L1 vertebra over the L2 vertebra.
Postero-central disc herniations with peridiscal osteophytes are noted at the D12-L1, L1-L2 and L2-L3 levels, indenting the dural theca anteriorly.
Type II degenerative marrow changes are noted adjacent to the L1-L2 and L5-S1 intervertebral discs.
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 D12-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 :
15.0 mm at L1-L2
15.0 mm at L2-L3
18.0 mm at L3-L4
16.0 mm at L4-L5
15.0 mm at L5-S1.
IMPRESSION :
1. Grade I spondylolisthesis of the L5 vertebra over the S1 vertebra with spondylolysis at the L5 level bilaterally and a posterior disc bulge with a peridiscal osteophyte at the L5-S1 level.
2. Postero-central disc herniations with peridiscal osteophytes at the D12-L1, L1-L2 and L2-L3 levels.