sb/ke/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzlata N. lmn / F / 35 yrs.
Referred by : Dr. Abc Xyzar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE (right more than left) with paresthesias since 1 year.

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 loss of water content of the L4-L5 and L5-S1 intervertebral discs.

There is Grade I spondylolisthesis of the L4 over the L5 vertebra and the L5 over the S1 vertebra without obvious spondylolysis.

There is a right paracentral disc herniation at the L5-S1 level indenting the traversing right S1 nerve root. Bilateral far lateral disc bulges are also noted at these levels. There is slight facetal hypertrophy at this level.

A posteriorly herniated disc is noted at the L4-L5 level with bilateral neural foraminal narrowing. There is also facetal and ligamentum flavum hypertrophy at that level. Bilateral small facet joint effusions are noted at the L4-L5 level with a small synovial cyst in relation to the right facet joint at the L4-L5 level, postero-laterally.




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-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 :

14.0 mm at L1-L2
13.0 mm at L2-L3
13.0 mm at L3-L4
11.0 mm at L4-L5
9.0 mm at L5-S1.

IMPRESSION :

1. Grade I spondylolisthesis of the L4 over the L5 vertebra and the L5 over the S1 vertebra without obvious spondylolysis.

2. A right paracentral disc herniation at the L5-S1 level indenting the traversing right S1 nerve root with slight facetal hypertrophy at this level.

3. A posteriorly herniated disc at the L4-L5 level with facetal and ligamentum flavum hypertrophy and canal stenosis.

4. Bilateral small facet joint effusions at the L4-L5 level with a small synovial cyst in relation to the right facet joint at the L4-L5 level, postero-laterally.