Date : 00.00.00
Name of the Patient : Abc Xyzy Fernalmn / M / 30 yrs.
Referred by : Dr. Abc Xyzcha.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache and pain in the left buttock since 6 years with numbness in the left foot since 6 months.
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 L5 over the S1 vertebra with spondylolysis at L5 vertebra.
A pseudo-posterior and left postero-lateral disc herniation is seen at the L5-S1 level with left neural foraminal narrowing. A sequestered disc fragment is noted in the left neural foramen at the L5-S1 level with impingement of the foraminal portion of the left L5 nerve root. This disc shows slight loss of water content.
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 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 :
15.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
17.0 mm at L4-L5
18.0 mm at L5-S1.
1. Grade I spondylolisthesis of the L5 over the S1 vertebra with spondylolysis of L5.
2. A pseudo-posterior disc herniation and a left postero-lateral disc herniation at the L5-S1 level with
a sequestered disc fragment in the left neural foramen at the L5-S1 level with impingement of the foraminal portion of the left L5 nerve root.