sb/ke/nl
Date : 00.00.00
Name of the Patient : Abc Xyz M. lmn / M / 31 yrs.
Referred by : Dr. Abc XyzSonawane / Dr. Abc Xyzhe.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O low backpain since 2 years.
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 intervertebral disc.
There is minimal forward translation of the L5 over the S1 vertebra. Probable spondylolysis is noted at L5 (please correlate with plain radiographs).
A postero-central disc herniation with peridiscal osteophyte is noted at the L4-L5 level with slight inferior migration of the disc.
Minimal posterior peridiscal osteophyte is seen at the L3-L4 level.
Type I, degenerative marrow change is noted adjacent to the L4-L5 disc.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 :
17.0 mm at L1-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
13.0 mm at L4-L5
17.0 mm at L5-S1.
IMPRESSION :
1. Minimal forward translation of the L5 over the S1 vertebra, with probable spondylolysis at L5.
2. A postero-central disc herniation at the L4-L5 level with slight inferior migration of the disc fragment.