Date : 00.00.00
Name of the Patient : Abc XyzDarlmn / M / 42 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with radiation of pain to the RLE.
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 mild forward listhesis of the L5 vertebra over the S1 vertebra. Also seen is spondylolysis of the L5 vertebra bilaterally.
There is a right paracentral extrusion indenting the thecal sac and the traversing right L5 nerve root at the L4-L5 level. A disc portion is seen to lie within the right anterior epidural space at the L5 vertebral level.
A small postero-central disc herniation is noted at the L5-S1 level. A small right paracentral disc herniation is seen to indent the thecal sac at the L3-L4 level.
There is an increased amount of fat within the epidural space at the L5 and S1 vertebral levels. The thecal sac shows a trifoiliate appearance and this may suggest epidural lipomatosis.
The L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content.
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 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 :
20.0 mm at L1-L2
19.0 mm at L2-L3
18.0 mm at L3-L4
18.0 mm at L4-L5
23.0 mm at L5-S1.
The MRI features are suggestive of :
1. Mild forward listhesis of the L5 vertebra over the S1 vertebra with spondylolysis of the L5 vertebra bilaterally.
2. A right paracentral disc extrusion indenting the traversing right L5 nerve root at the L4-L5 level.
3. Epidural lipomatosis at the L5 and S1 vertebral levels.
4. A small postero-central disc herniation at the L5-S1 level.
5. A small right paracentral disc herniation at the L3-L4 level.