Name of the Patient : Abc Xyz Bheslmn / M / 68 yrs.
Referred by : Dr. Abc Xyzonawalla.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with radiating to BLE (right more than left) with paresthesias since 2 years.
H/O fall 2 years ago.
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 appears to be sacralization of the L5 vertebra and is as marked on the film. Please correlate with plain radiographs.
There is straightening of the lumbar spine. The lumbar intervertebral discs except at the L5-S1 level show loss of water content.
There is Grade II spondylolisthesis of the L3 vertebra over the L4 vertebra.
A large postero-central disc extrusion, more to the right of the midline is seen to compress the thecal sac and impinge both traversing L4 nerve roots at the L3-L4 level. A disc portion is seen to migrate superiorly.
The L3-L4 facet joints show hypertrophic degenerative changes.
- 2 - Scan-00007
A postero-central disc protrusion is seen to indent the thecal sac at the L4-L5 level. Facetal hypertrophy is noted at the L2-L3 and L4-L5 levels.
There is atrophy of the paraspinal muscles (in the dorso-lumbar region) and in both psoas muscles.
The lumbar vertebral bodies 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 L1 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
13.0 mm at L2-L3
4.0 mm at L3-L4
8.0 mm at L4-L5
8.0 mm at L5-S1.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebra. Please correlate with plain radiographs.
2. Grade II spondylolisthesis of the L3 vertebra over the L4 vertebra.
3. A large postero-central disc extrusion, more to the right of the midline at the L3-L4 level.
4. Hypertrophic facetal arthropathy with canal stenosis at the L3-L4 level.