Date : 00.00.00
Name of the Patient : Abc Xylmn / F / 38 yrs.
Referred by : Dr. Abc Xyzauhan.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE since 20 days.
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 translation of the L5 over the S1 vertebra with spondylolysis at the L5 level bilaterally.
A pseudo-posterior disc herniation is seen at the L5-S1 level. The L5-S1 intervertebral disc shows loss of water content.
A posterior and a left far lateral disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and the extraforaminal portion of the left L4 nerve root (scan 102.1, 104.8).
Type II degenerative changes are seen in the S1 vertebral body adjacent to the L5-S1 intervertebral disc and the antero-superior portion of the L4 vertebra.
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.
- 2 - scan-00001
The conus medullaris terminates at the L1 level and the thecal sac terminates at the S2 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
21.0 mm at L2-L3
18.0 mm at L3-L4
17.0 mm at L4-L5
17.0 mm at L5-S1.
The MRI features are suggestive of :
1. Forward translation of the L5 over the S1 vertebra with spondylolysis at the L5 level bilaterally.
2. A pseudo-posterior disc herniation at the L5-S1 level.
3. A posterior and a left far lateral disc herniation at the L4-L5 level with indentation upon the extraforaminal portion of the left L4 nerve root.