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ke/bv/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzathi Klmn / F / 60 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with (occasional) paresthesias since 6 months.

EXAMINATION :

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.

OBSERVATION :

There is Grade II spondylolisthesis of the L5 over the S1 vertebra with spondylolysis of the L5 vertebra bilaterally.

A large posterior disc herniation is seen at the L5-S1 level with anterior compression of the thecal sac and bilateral neural foraminal narrowing. There is impingement of the foraminal portion of the L5 nerve roots bilaterally. This disc shows loss of water content. Hypointense areas are noted within this disc on all the pulse sequences suggestive of calcification/vacuum phenomena.

A small posterior disc bulge is noted at the L4-L5 level. The lumbar intervertebral discs show loss of water content.

Type I/III degenerative changes are noted in the L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral disc and Type II degenerative changes in the L5 vertebra adjacent to the L4-L5 intervertebral disc.
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The rest of the lumbar vertebral bodies reveal normal signal intensity. The the visualized pre and paravertebral soft tissues are unremarkable.

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 :

14.0 mm at L1-L2
14.0 mm at L2-L3
13.0 mm at L3-L4
13.0 mm at L4-L5
9.0 mm at L5-S1.

IMPRESSION :

1. Grade II spondylolisthesis of the L5 over the S1 vertebra with spondylolysis of the L5 vertebra bilaterally.

2. A large posterior disc herniation with impingement of the foraminal portion of the L5 nerve roots bilaterally with a tight canal at the L5-S1 level.


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