Date : 00.00.00
Name of the Patient : Abc Xyz lmn / F / 45 yrs.
Referred by : Dr. Abc Xyzlkarni / Dr. Abc Xyzhah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias since 3-4 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 loss of water content of the L3-L4, L4-L5 and L5-S1 intervertebral discs.
There is Grade I spondylolisthesis of the L5 over the S1 vertebra with probable spondylolysis at the L5 bilaterally. A resultant pseudo-posterior disc bulge is noted at the L5-S1 level. Slight compromise of the neural foramen at the L5-S1 level is noted bilaterally.
A small posterior disc bulge with peridiscal osteophytes is noted at the L4-L5 level.
A small posterior disc herniation with peridiscal osteophytes is noted at the L3-L4 level.
Type II degenerative marrow changes are noted adjacent to the L5-S1 intervertebral disc.
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.
There is evidence of a syrinx in the lower dorsal spinal cord.
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 :
17.0 mm at L1-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
15.0 mm at L4-L5
15.0 mm at L5-S1.
Screening images of the dorsal spine reveal, a syrinx in the centre of the cord over D9 to D11 vertebral levels. The spinal cord at the D9 level appears slightly irregular with slight atrophy of the cord above it. A contrast enhanced study would be worthwhile to rule out the cause of the syrinx.
1. Grade I spondylolisthesis of the L5 over the S1 vertebra with probable spondylolysis at the L5 bilaterally. A resultant pseudo-posterior disc bulge is noted at the L5-S1 level.
2. A small posterior disc bulge with peridiscal osteophytes at the L4-L5 level.
3. A small posterior disc herniation with peridiscal osteophytes at the L3-L4 level.
4. A syrinx in the lower dorsal spinal canal.