sb/ke/rg/nl
Name of the Patient : Abc Xyz V. Relmn / F / 48 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE (left more than right) with paresthesias since 2 months.
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 reduction in height and loss of water content of the L4-L5 and L5-S1 intervertebral discs. These discs show evidence of vacuum phenomenon/calcium.
There is Grade I spondylolisthesis of the L4 over the L5 vertebra and the L5 over the S1 vertebra with probable spondylolysis of the L4 and L5 vertebrae, respectively.
A pseudo-posterior disc bulge is noted at the L5-S1 level with bilateral neural foraminal narrowing and impingement of the foraminal portion of the L5 nerve root. Slight facetal and ligamentum flavum hypertrophy is also noted at this level.
There is a posteriorly herniated disc at the L4-L5 level with bilateral neural foraminal narrowing and impingement of the exiting L4 nerve root in the left neural foramen at the L4-L5 level. Slight facetal hypertrophy is noted at the L4-L5 level with ligamentum flavum hypertrophy at the L4 vertebral level.
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Slight facetal hypertrophy is noted at the L2-L3 and L3-L4 levels.
Type II degenerative marrow changes are noted adjacent to the L4-L5 disc and Type I/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 rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1-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 :
17.0 mm at L1-L2
17.0 mm at L2-L3
14.0 mm at L3-L4
11.0 mm at L4-L5
14.0 mm at L5-S1.
IMPRESSION :
1. Grade I spondylolisthesis of the L4 over the L5 vertebra and the L5 over the S1 vertebra with probable spondylolysis of the L4 and L5 vertebrae, respectively.
2. A pseudo-posterior disc bulge is noted at the L5-S1 level with slight facetal and ligamentum flavum hypertrophy at this level and impingement of the foraminal portion of the L5 nerve root.
3. A posteriorly herniated disc at the L4-L5 level with impingement of the exiting L4 nerve root in the left neural foramen at the L4-L5 level and slight facetal hypertrophy at this level.
4. Slight facetal hypertrophy at the L2-L3 and L3-L4 levels.