sb/bv
Date : 00.00.00

Name of the Patient : Abc XyzEngilmn / M / 62 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O severe backache radiating to the RLE since 6 months.
H/O surgery for PID in 0000.

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 L5 over the S1 vertebra and L4 over the L5 vertebra. Probable spondylolysis at the L5 level is noted.

There is evidence of laminectomy at the L5 vertebral level with post-operative changes in the soft tissues in the posterior lumbar region at these levels.

A posteriorly bulging disc with posterior peridiscal osteophytes is noted at the L5-S1 level.

A pseudo-posterior disc herniation with peridiscal osteophytes is noted at the L4-L5 level with bilateral neural foraminal narrowing. There is facetal and ligamentum flavum hypertrophy at the L4-L5 and L5 levels with a tight lumbar canal at these levels. Minimal facet joint effusion is noted at the L4-L5 and L5 levels.

Small posterior disc bulges with peridiscal osteophytes are noted at the L3-L4, L2-L3 , L1-L2 and D12-L1 levels.

The intrathecal nerve roots show normal distribution.
..2/.






- 2 -

.
The lumbar vertebral bodies show spotty fatty marrow changes. 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 :

16.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
9.0 mm at L4-L5

Screening T2 Weighted sagittal images of the dorsal spine reveal reduction in height and loss of water content of the dorsal intervertebral discs. Posterior peridiscal osteophytes are noted in the lower dorsal region. Slight facetal hypertorphy is also noted at the D9-D10 and D10-D11 levels.

IMPRESSION :

1. Post-operative status.

2. Grade I spondylolisthesis of the L5 over the S1 vertebra and L4 over the L5 vertebra with probable spondylolysis at L5 level is noted.

3. A posteriorly bulging disc with posterior peridiscal osteophytes at the L5-S1 level.

4. A pseudo-posterior disc herniation with peridiscal osteophytes at the L4-L5 level with bilateral neural foraminal narrowing with facetal and ligamentum flavum hypertrophy at the L4-L5 and L5 levels with a tight lumbar canal at these levels.

As compared to the previous MRI (scan no:448) dated 00.00.00, there is now evidence of a Grade I spondylolisthesis of the L4 over the L5 vertebra with a tight lumbar canal at the L4-L5 level.