Date : 00.00.00
Name of the Patient : Abc XyzRlmn / F / 30 yrs.
Referred by : Dr. Abc Xyzrekh
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE.
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 forward subluxation of the L5 vertebra over the S1 vertebra. Also seen is mild retroplacement of the L4 vertebra over the L5 vertebra.
A large postero-central disc herniation is seen at the L5-S1 level with anterior indentation of the thecal sac. There is superior migration of the disc which is seen to lie posterior to the L5 vertebral body. This disc shows loss of water content.
A small postero-central disc herniation is noted at the L4-L5 level.
There is a suspicious break of the pars interarticularis of the L5 vertebra. Please correlate with plain radiographs.
There appears to be a small Tarlovs perineurial cyst within the spinal canal at the S1/S2 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 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
17.0 mm at L2-L3
16.0 mm at L3-L4
15.0 mm at L4-L5
10.0 mm at L5-S1.
1. Forward subluxation of the L5 vertebra over the S1 vertebra.
2. Probable spondylolysis of the L5 vertebra. Please correlate with plain radiographs.
3. A large postero-central disc herniation at the L5-S1 level with superior migration of the disc and lying posterior to the L5 vertebral body.
4. A small postero-central disc herniation at the L4-L5 level.