ke/hs/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz M. Shlmn / F / 50 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE (right more than left) with numbness in the RLE since 2-3 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 forward translation of the L4 vertebra over the L5 vertebra without obvious spondylolysis.

A pseudoposterior disc bulge is seen at the L4-L5 level with anterior indentation of the thecal sac. The L4-L5 facet joints show hypertrophic degenerative changes with mild neural foraminal narrowing bilaterally.

A small posterior disc herniation is noted at the L3-L4 level. A posterior disc bulge is noted at the L5-S1 level. The right L5-S1 facet joint shows hypertrophic degenerative changes. Bilateral far lateral (extraforaminal) disc bulges are seen at the L4-L5 level.

Anterior disc herniations are noted over the D12-L1 to the L4-L5 levels. The L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content.

Small posterior peridiscal osteophytes are noted at the L3-L4, L4-L5 and L5-S1 levels.
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The rest of the lumbar facet joints show mild degenerative changes.

Type II degenerative changes are noted in the lumbar vertebrae adjacent to the intervertebral discs.

The remaining intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1-L2 level and the thecal sac terminates at the S1-S2 level.

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

20.0 mm at L1-L2
18.0 mm at L2-L3
18.0 mm at L3-L4
12.0 mm at L4-L5
15.0 mm at L5-S1.

IMPRESSION :

1. Forward translation of the L4 vertebra over the L5 vertebra.

2. A pseudoposterior disc bulge at the L4-L5 level with hypertrophic facetal arthropathy at this level.

3. A small posterior disc herniation at the L3-L4 level.

4. A posterior disc bulge at the L5-S1 level and hypertrophic facetal arthropathy on the right side at this level.

5. Small posterior peridiscal osteophytes at the L3-L4, L4-L5 and L5-S1 levels.

6. Mild degenerative changes of rest of the lumbar facet joints.