hs/sb/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzli Slmn / M / 63 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with radiation of pain to BLE with paresthesias.

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.

The dorsal spine was screened with 4 mm thick T2 Weighted sagittal images and 5 mm thick T2 Weighted axial images through the region of interest.

FEW IMAGES SHOW PATIENT MOTION.

OBSERVATION :

There appears to be partial sacralization of the L5 vertebra on the right side and the L1 vertebra is as marked on the film.

There is Grade I spondylolisthesis of the L4 vertebra over the L5 vertebra. The L4-L5 facet joints show severe hypertrophic degenerative changes.

A large postero-central disc extrusion with peridiscal osteophytes is seen to indent the cord at the D10-D11 level. The cord at the D10-D11 and D11 levels show a hyperintense signal on the T2 Weighted images suggestive of cord edema/contusion/ischemia. The D10-D11 facet joints show degenerative changes with a resultant tight canal at this level.
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A posterior disc herniation is seen to indent the thecal sac at the L4-L5 level with resultant bilateral neural foraminal narrowing.

A small posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L3-L4 level.

There are small right postero-lateral (foraminal) disc herniations narrowing the right neural foramina at the L1-L2 and L2-L3 levels.

Far lateral disc herniations are seen bilaterally at the L3-L4 and L4-L5 levels and on the right side at the L1-L2 and L2-L3 levels.

The L1-L2, L2-L3 and L3-L4 facet joints show degenerative changes.

The lumbar intervertebral discs show loss of water content. The lumbar vertebral bodies show spotty fatty marrow changes.

The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D11-D12 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
16.0 mm at L2-L3
16.0 mm at L3-L4
11.0 mm at L4-L5
11.0 mm at L5-S1.
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- 3 - Scan-00009


IMPRESSION :

The MRI features are suggestive of :

1. Partial sacralization of the L5 vertebra on the right side.

2. Grade I spondylolisthesis of the L4 vertebra over the L5 vertebra with hypertrophic facetal arthropathy and a tight canal at the L4-L5 level.

3. A posterior disc herniation at the L4-L5 level.

4. A small posterior herniation at the L3-L4 level.

5. A large postero-central disc extrusion with peridiscal osteophytes and a tight canal at the D10-D11 level.

6. Altered cord signal at the D10-D11 and D11 levels may represent cord edema/contusion/ischemia.