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Date : 00.00.00

Name of the Patient : Abc Xyz S. Jogllmn / M / 42 yrs.
Referred by : Dr. Abc Xyzrani.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

H/O sudden onset of backache since 8 days.

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 I spondylolisthesis of the L5 vertebra over the S1 vertebra. Also seen is slight retroplacement of the rest of the lumbar vertebrae.

There is a postero-central disc herniation at the L5-S1 level with slight superior migration of the disc. A small right far lateral disc herniation is seen to indent the exiting right L5 nerve root at the L5-S1 level.

Small posterior disc herniations with peridiscal osteophytes are seen to indent the thecal sac and narrow both neural foramina at the L2-L3 and L4-L5 levels.

A left paracentral disc herniation with peridiscal osteophytes is seen to indent the thecal sac at the L1-L2 level.

There is a small postero-central disc herniation with peridiscal osteophytes at the L3-L4 level.



The L4-L5 and L5-S1 facet joints show hypertrophic degenerative changes. The rest of the lumbar facet joints also show mild degenerative changes.

The lumbar intervertebral discs show loss of water content.

The lumbar vertebral bodies show Type II degenerative changes.

Spina bifida is noted at the L5 and S1 levels. Fat is noted within the filum terminale at the L5 and S1 levels.

There is slight atrophy of the paraspinal muscles in the lumbar region.

The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L2 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 :

.0 mm at L1-L2
.0 mm at L2-L3
.0 mm at L3-L4
.0 mm at L4-L5
.0 mm at L5-S1.

IMPRESSION :

1. Grade I spondylolisthesis of the L5 vertebra over the S1 vertebra.

2. A postero-central disc herniation at the L5-S1 level with slight superior migration of the disc.
..3/.






- 3 - Scan-00004



3. A small right far lateral disc herniation indenting the exiting right L5 nerve root at the L5-S1 level.

4. Small posterior disc herniations with peridiscal osteophytes at the L2-L3 and L4-L5 levels.

5. A left paracentral disc herniation with peridiscal osteophytes at the L1-L2 level.

6. A small postero-central disc herniation with peridiscal osteophytes at the L3-L4 level.

7. Hypertrophic facetal arthropathy at the L4-L5 and L5-S1 levels.


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