Date : 00.00.00
Name of the Patient : Abc Xyzta Gaolmn / F / 41 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since 1 month.
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.
The L5-S1 intervertebral disc shows loss of water content.
There is Grade II spondylolisthesis of the L5 over the S1 vertebra with spondylolysis at the L5 level bilaterally.
A large pseudoposterior disc herniation is seen at the L5-S1 level with posterior peridiscal osteophytes and bilateral neural foraminal narrowing. There is superior migration of the disc which is seen to lie in the right lateral recess of L5 with indentation upon the right L5 nerve root. The L5-S1 facet joints show slight hypertrophic degenerative changes. There is also narrowing of the left neural foramen with obliteration of the fat around the nerve.
A small posterior disc herniation is seen at the L4-L5 level. The L4-L5 facet joint on the left show mild degenerative change.
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.
A hemangioma with fatty changes is seen in the D10 vertebral body.
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 :
14.0 mm at L1-L2
13.0 mm at L2-L3
16.0 mm at L3-L4
16.0 mm at L4-L5
16.0 mm at L5-S1.
1. Grade II spondylolisthesis of the L5 over the S1 vertebra with spondylolysis at the L5 level bilaterally.
2. A large pseudoposterior disc herniation at the L5-S1 level with posterior peridiscal osteophytes with superior migration of the disc lying in the right lateral recess of L5 with indentation upon the right L5 nerve root.
3. A small posterior disc herniation at the L4-L5 level.