Date : 00.00.00
Name of the Patient : Abc Xyzohammelmn / F / 40 yrs.
Referred by : Dr. Abc Xyzwhale.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RUE and RLE since 3 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 is Grade I spondylolisthesis of the L4 vertebra over the L5 vertebra with probable spondylolysis at L4. A resultant pseudoposterior and right postero-lateral disc herniation is noted at the L4-L5 level, with bilateral neural foraminal narrowing. Probable indentation on the traversing right L5 nerve root and indentation upon both the foraminal L4 nerve roots is noted. The L4-L5 intervertebral disc shows loss of water content. Type II degenerative marrow changes are noted adjacent to the L4-L5 disc.
Small posterior disc bulge is noted at the L3-L4 level.
The rest of 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 D12-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 :
16.0 mm at L1-L2
15.0 mm at L2-L3
16.0 mm at L3-L4
12.0 mm at L4-L5
10.0 mm at L5-S1.
1. Grade I spondylolisthesis of the L4 vertebra over the L5 vertebra with probable spondylolysis at L4, bilaterally.
2. A pseudoposterior and right postero-lateral disc herniation at the L4-L5 level, with bilateral neural foraminal narrowing. Probable indentation on the traversing right L5 nerve root and foraminal L4 nerve roots bilaterally, is noted.