sb/ke/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzn Vanilmn / F / 77 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 1 year.

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 scoliosis of the dorso-lumbar spine with convexity to the left.

There is loss of water content of the lumbar intervertebral discs. The L4-L5 and L5-S1 intervertebral discs show evidence of calcium/vacuum phenomena.

There is Grade I spondylolisthesis of the L4 over the L5 vertebra without obvious spondylolysis.

A small posterior disc bulge is noted at the L5-S1 level with bilateral neural foraminal narrowing.

A pseudo-posterior disc herniation and bilateral far lateral disc herniations are noted at the L4-L5 level, with bilateral neural foraminal narrowing. Indentation on the extraforaminal segment of the L5 nerve roots is noted bilaterally. There is also facetal hypertrophy and a resultant canal stenosis at the L4-L5 level.
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A posterior and a right far lateral disc bulge is noted at the L3-L4 level with right neural foraminal narrowing and indentation on the extraforaminal segment of the right L3 nerve root. Slight facetal hypertrophy is also noted at this level.

There is a left far lateral disc bulge at the L2-L3 level.

A right postero-lateral disc herniation is noted at the L1-L2 level with right neural foraminal narrowing.

The lumbar vertebral bodies reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

A dilated right renal pelvis is noted.

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 :

16.0 mm at L1-L2
17.0 mm at L2-L3
14.0 mm at L3-L4
10.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. Grade I spondylolisthesis of the L4 over the L5 vertebra without obvious spondylolysis.

2. A small posterior disc bulge at the L5-S1 level.
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3. A pseudo-posterior disc herniation and bilateral far lateral disc herniations at the L4-L5 level, with indentation on the extraforaminal segments of the L5 nerve roots bilaterally. There is also facetal hypertrophy and resultant canal stenosis at the L4-L5 level.

4. A posterior and a right far lateral disc bulge at the L3-L4 level indenting the extraforaminal segment of the right L3 nerve root. Slight facetal hypertrophy is also noted at this level.

5. A left far lateral disc bulge at the L2-L3 level.

6. A right postero-lateral disc herniation at the L1-L2 level.