hs/ke/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzlmn / F / 35 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias since 10-12 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 retrolisthesis of the L5 vertebra over the S1 vertebra.

A posterior disc herniation with a peridiscal osteophyte is seen to indent the thecal sac and narrow both neural foramina at the L5-S1 level. An anterior disc herniation is seen at this level. Also seen is mild facetal and ligamentum flavum hypertrophy at this level. Bilateral far lateral (extraforaminal) disc herniations are noted at the L5-S1 level.

A large postero-central disc herniation with a peridiscal osteophyte is seen to indent the thecal sac at the L4-L5 level. A disc portion is seen to lie within the anterior epidural space at the L4 vertebral level.

Type I degenerative changes (hypointense on the T1 Weighted images and hyperintense on the T2 Weighted images) are seen within the L5 vertebra adjacent to the L5-S1 intervertebral disc.

The L4-L5 and L5-S1 intervertebral discs show loss of water content.
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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 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 :

18.0 mm at L1-L2
18.0 mm at L2-L3
16.0 mm at L3-L4
9.0 mm at L4-L5
12.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. Retrolisthesis of the L5 vertebra over the S1 vertebra.

2. A posterior disc herniation with a peridiscal osteophyte
at the L5-S1 level.

3. A large postero-central disc herniation with a peridiscal osteophyte at the L4-L5 level with a disc portion lying within the anterior epidural space at the L4 vertebral level and resultant canal stenosis at this level.

4. Bilateral far lateral (extraforaminal) disc herniations at the L5-S1 level.

5. Mild facetal and ligamentum flavum hypertrophy at the L5-S1 level with a tight canal.