Date : 00.00.00
Name of the Patient : Abc Xyzh Sundlmn / M / 37 yrs.
Referred by : Dr. Abc Xyz.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O low back pain radiating to BLE, right more than left, since 0000.
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.
There is loss of water content of the L5-S1 intervertebral disc.
There is Grade I spondylolisthesis of the L5 over the S1 vertebra, with spondylolysis at the L5, bilaterally. A resultant pseudoposterior disc bulge is noted at the L5-S1 level. There is compromise of the neural foramen, bilaterally, with impingement of the left L5 nerve root in the left neural foramen at the L5-S1 level.
Slight facetal hypertrophy is noted at the L4-L5 level.
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 L1 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 :
21.0 mm at L1-L2
20.0 mm at L2-L3
20.0 mm at L3-L4
15.0 mm at L4-L5
16.0 mm at L5-S1.
Screening, T2 Weighted sagittal images of the cervical spine reveal posterior peridiscal osteophytes at the C4-C5, C5-C6 and C6-C7 levels, the largest one being at the C6-C7 level.
1. Grade I spondylolisthesis of the L5 over the S1 vertebra with spondylolysis at L5, bilaterally.
2. A pseudoposterior disc bulge at the L5-S1 level.
3. Compromise of the neural foramen at the L5-S1 level, bilaterally with impingement of the left L5 nerve root in the left neural foramen at the L5-S1 level.