Date : 00.00.00
Name of the Patient : Abc XyzShafi Merclmn / M / 43 yrs.
Referred by : Dr. Abc Xyzoshipura.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE (right more than left) with numbness since 2 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 sacralization of the L5 vertebra and the L2 vertebral body is as marked on the film.
There is scoliosis of the spine with convexity to the left side.
There is loss of water content of the L4-L5 intervertebral disc.
There is Grade I spondylolisthesis of the L4 over the L5 vertebra with spondylolysis at L4, bilaterally. A pseudo-posterior disc herniation is noted at the L4-L5 level with bilateral neural foraminal narrowing and probable indentation upon the foraminal L4 nerve roots. Slight superior migration of the disc fragment is noted, more to the right of the midline.
A minimal posterior disc bulge is noted at the L3-L4 level.
Facetal hypertrophy is noted at the L3-L4, L4-L5 and L5-S1 levels.
Schmorls nodes are noted in the lumbar region.
A hemangioma with fat content is noted at the D10 and D12 vertebral levels.
Slight anterior wedging of the D12 vertebral body is noted.
Fat is noted in the filum terminale at the L3 and L4 vertebral levels.
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 L2 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 :
15.0 mm at L1-L2
20.0 mm at L2-L3
20.0 mm at L3-L4
18.0 mm at L4-L5
12.0 mm at L5-S1.
1. Sacralization of the L5 vertebra.
2. Grade I spondylolisthesis of the L4 over the L5 vertebra with spondylolysis at L4, bilaterally.
3. A pseudo-posterior disc herniation at the L4-L5 level with slight superior migration of the disc fragment and bilateral neural foraminal narrowing.
4. Facetal hypertrophy at the L3-L4, L4-L5 and L5-S1 levels.