hs/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz V. Hlmn / M / 54 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache on the left side since 1 year.
Known C/O renal cell carcinoma for which left radical nephrectomy was done in 0000.

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 with spondylolysis of the L5 vertebra bilaterally.

A posterior disc herniation with peridiscal osteophytes is seen to indent the thecal sac and narrow both neural foramina with indentation upon the foraminal portion of the exiting L5 nerve roots at the L5-S1 level. Bilateral far lateral (extraforaminal) disc herniations are seen to indent the extraforaminal portion of the exiting nerve L5 roots at this level.

A small posterior disc herniation with peridiscal osteophytes is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level. Bilateral far lateral (extraforaminal) disc herniations are seen at this level.
Scan-00003


The L4-L5 and L5-S1 facet joints show hypertrophic degenerative changes.

A left far lateral (extraforaminal) disc bulge is noted at the L1-L2 level. The L4-L5 and L5-S1 intervertebral discs show loss of water content.

Spina bifida of the S1 vertebra is noted.

The left kidney is not visualized, the result of previous surgery. Hyperintense signal on the T2 Weighted images seen in the left paraspinal muscles at the L1 and L2 levels may represent post-operative/inflammatory changes.

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 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
18.0 mm at L2-L3
17.0 mm at L3-L4
16.0 mm at L4-L5
7.0 mm at L5-S1.
..3/.














- 3 - Scan-00003

IMPRESSION :

1. Grade I spondylolisthesis of the L5 vertebra over the S1 vertebra with spondylolysis of the L5 vertebra bilaterally.

2. A posterior disc herniation with peridiscal osteophytes indenting the foraminal portion of the exiting L5 nerve roots at the L5-S1 level.

3. Bilateral far lateral (extraforaminal) disc herniations at the L5-S1 level indenting the extraforaminal portion of the exiting L5 nerve roots at this level.

4. A small posterior disc herniation with peridiscal osteophytes at the L4-L5 level with bilateral far lateral (extraforaminal) disc herniations at this level.

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

6. Canal stenosis at the L5-S1 level.