Date : 00.00.00
Name of the Patient : Abc Xyzh lmn / M / 32 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 2 years which has increased since 1 1/2 months.
H/O being operated for pelvis with sacro-iliac joints disruption on 00.00.00.
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 L1 vertebra is as marked on the film.
There is retrolisthesis of the L4 over the L5 vertebral body. A pseudo-posterior disc herniation with peridiscal osteophytes is noted at the L4-L5 level with inferior migration of the disc posterior to the L5 vertebral body. The L4-L5 intervertebral disc shows slight loss of water content. A probable, small, sequestered disc fragment is noted at the L5 vertebral level, more to the right of the midline.
A Schmorls node is seen in the superior aspect of the D12 vertebral body with apparent wedging of the D12 vertebra.
Type II degenerative changes are noted in the L4 and L5 vertebral bodies adjacent to the L4-L5 intervertebral disc.
The facet joints in the lower lumbar region appear slightly hypertrophied.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12 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 :
16.0 mm at L1-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
13.0 mm at L4-L5
9.0 mm at L5-S1.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebra.
2. Retrolisthesis of the L4 over the L5 vertebral body.
3. A pseudo-posterior disc herniation with peridiscal osteophytes at the L4-L5 level with inferior migration of the disc posterior to the L5 vertebral body. A probable, small, sequestered disc fragment is noted, at L5 vertebral level, to the right.
4. Slight anterior wedging of D12 body.