hs/ke/rg.
Date : 00.00.00

Name of the Patient : Abc Xyznjan S.lmn / F / 54
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with numbness since 1 1/2 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.

FEW IMAGES SHOW PATIENT MOTION.

OBSERVATION :

There appears to be sacralization of the L5 vertebra and it is as marked on the film. Please correlate with plain radiographs.

There is Grade I spondylolisthesis of the L4 vertebra over the L5 vertebra with break of the pars interarticularis of the L4 vertebra bilaterally.

A posterior disc herniation is seen to indent the thecal sac and cause slight neural foraminal narrowing at the L4-L5 level. This intervertebral disc shows marked loss of water content.

There are bilateral far lateral (extraforaminal) disc herniations indenting the exiting L4 nerve roots at the L4-L5 level. The facet joints at this level show hypertrophic degenerative changes.

Bilateral far lateral (extraforaminal) disc bulges are noted at the L3-L4 level with mild indentation upon the extraforaminal portion of the right L3 nerve root.
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The L2-L3 and L3-L4 intervertebral disc show mild loss of water content.

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 S1 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

15.0 mm at L1-L2
14.0 mm at L2-L3
14.0 mm at L3-L4
8.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. Sacralization of the L5 vertebra. Please correlate with plain radiographs.

2. Grade I spondylolisthesis of the L4 vertebra over the L5 vertebra with spondylolysis of the L4 vertebra bilaterally.

3. A posterior disc herniation with hypertrophic facetal arthropathy and resultant canal stenosis at the L4-L5 level.

4. Bilateral far lateral (extraforaminal) disc herniations indenting the exiting L4 nerve roots at the L4-L5 level.

5. Bilateral far lateral disc bulge at the L3-L4 level with indentation upon the extraforaminal portion of the right L3 nerve root.