sb/bv/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Obelmn / F / 55 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias since 6-7 months.

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 lumbar intervertebral discs.

There is Grade I spondylolisthesis of the L3 over the L4 vertebra with suspicious spondylolysis of L3 bilaterally. A resultant pseudo-posterior disc herniation is noted at the L3-L4 level with thecal sac compression and bilateral neural foraminal narrowing. The L3 nerve roots are impinged in their corresponding neural foramen. There is also hypertrophic facetal arthropathy and canal stenosis at the L3-L4 level. Effusion is also noted within the right facet joint at this level.

A posteriorly herniated disc is noted at the L4-L5 level with thecal sac compression and bilateral neural foraminal narrowing. Slight facetal and ligamentum flavum hypertrophy is noted at this level.






A small postero-central disc herniation is noted at the L5-S1 level.

A right far lateral disc herniation is noted at the L1-L2 and L2-L3 levels with slight right neural foraminal narrowing.

Slight facet joint effusion is noted at the L3-L4 level.

Type I degenerative marrow changes are noted adjacent to the L3-L4 disc and Type II degenerative marrow changes are noted adjacent to the rest of the intervertebral discs.

Anterior disc herniations are noted at the L2-L3 and L3-L4 levels.

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 S2 level. The CSF in the lower lumbar canal (below L5 vertebra) appears significantly brighter than the CSF above on the T2 Weighted images (? xanthochromic).

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

13.0 mm at L1-L2
13.0 mm at L2-L3
7.0 mm at L3-L4
8.0 mm at L4-L5
8.0 mm at L5-S1.

Screening of the dorsal spine reveals no feature of note.
..3/.










- 3 - Scan-00006


IMPRESSION :

1. Grade I spondylolisthesis of the L3 over the L4 vertebra with suspicious spondylolysis.

2. A pseudo-posterior disc herniation at the L3-L4 level with bilateral neural foraminal narrowing with impingement of the L3 nerve roots in their corresponding neural foramen with hypertrophic facetal arthropathy and canal stenosis at this level.

3. Posteriorly herniated disc at the L4-L5 level with bilateral neural foraminal narrowing and slight facetal hypertrophy at this level.

4. A small postero-central disc herniation at the L5-S1 level.

5. A right far lateral disc herniation at the L1-L2 and L2-L3 levels with slight right neural foraminal narrowing.

6. Slight facet joint effusion at the L4-L5 level bilaterally and on the right at the L3-L4 level.

7. Lumbar canal stenosis at the L3-L4 and L4-L5 levels.