Date : 00.00.00
Name of the Patient : Abc Xyz Faglmn / M / 45 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with numbness since 3-4 years.
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 appears to be sacralization of the L5 vertebra and the L1 vertebra is as marked on the film. There is loss of normal lumbar lordosis.
The lumbar vertebrae are more hypointense than normal marrow
on the T1 Weighted images. These are isointense to marrow on the T2 Weighted images and this may be suggestive of a preponderance of haematopoietic marrow (? anemic).
There is retrolisthesis of the L4 vertebra over the L5 vertebra with a posterior disc herniation at the L4-L5 level and anterior indentation of the thecal sac. There is slight inferior migration of a disc portion posterior to the L5 vertebral body.
Ligamentum flavum hypertrophy is also noted at this level.
The L4-L5 intervertebral disc shows loss of water content. The L4-L5 facet joints show mild degenerative changes.
Fat is noted in the filum terminale at the L2 and L3 vertebral levels.
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 S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
18.0 mm at D12-L1
18.0 mm at L1-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
10.0 mm at L4-L5
9.0 mm at L5-S1.
1. Sacralization of the L5 vertebra. Please correlate with plain radiographs.
2. Altered signal of the lumbar vertebrae may be suggestive of a preponderance of haematopoietic marrow (? anemic).
3. Retrolisthesis of the L4 vertebra over the L5 vertebra with a posterior disc herniation at the L4-L5 level and slight inferior migration of a disc portion posterior to the L5 vertebral body and ligamentum flavum hypertrophy and mild facetal arthropathy at the L4-L5 level.