Date : 00.00.00
Name of the Patient : Abc XyzTibrelmn / M / 67 yrs.
Referred by : Dr. Abc Xyzra.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O stiffness of back with radiating pain to the RLE and paresthesias since 2 years which has increased since 6 months.
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.
After administration of contrast, the following parameters were used :
5 mm thick T1 Weighted sagittal and axial images with fat saturation.
3 mm thick T1 Weighted coronal images.
There appears to be partial sacralization of the L5 vertebra on the left side and it is as marked on the film. Please correlate with plain radiographs.
There is Grade I spondylolisthesis of the L4 vertebra over the L5 vertebra.
A small posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level. The L4-L5 facet joints show hypertrophic degenerative changes, bilaterally.
- 2 - Scan - 00005
Mild ligamentum flavum hypertrophy is noted at the L4-L5 and L5 vertebral levels. A mild posterior disc bulge is noted at the L3-L4 level.
After contrast administration there is no enhancement along the intrathecal nerve roots in the lumbar region or within the visualized lumbar vertebral bodies or the meninges.
The L2-L3, L3-L4 and L4-L5 intervertebral discs show loss of water content.
The 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 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 :
18.0 mm at L1-L2
19.0 mm at L2-L3
17.0 mm at L3-L4
12.0 mm at L4-L5
9.0 mm at L5-S1.
The MRI features are suggestive of :
1. Partial sacralization of the L5 vertebra. Please correlate with plain radiographs.
2. Grade I spondylolisthesis of the L4 vertebra over the L5 vertebra.
3. A small posterior disc herniation and hypertrophic facetal arthropathy with a tight canal at the L4-L5 level.