ke/sb/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzlal Dlmn / M / 71 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias since 4-5 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 Grade I spondylolisthesis of the L5 over the S1 vertebra with bilateral spondylolysis at the L5 level.

A pseudoposterior disc herniation is seen at the L5-S1 level. A right far lateral disc herniation is also noted at this level with impingement of the foraminal portion of the right L5 nerve root.

Diffuse posterior disc herniations are seen at the L3-L4 and L4-L5 levels with anterior indentation of the thecal sac and bilateral neural foraminal narrowing.

Small posterior disc herniations are noted at the L1-L2 and L2-L3 levels.

Anterior disc herniations are noted over the L1-L2 to the L4-L5 levels. The lumbar intervertebral discs show loss of water content.

Anterior and posterior peridiscal osteophytes are seen over the L1-L2 to L4-L5 levels.

The L3-L4 and L4-L5 facet joints show hypertrophic degenerative changes. Effusion is seen within the L3-L4 facet joint on the left side and L4-L5 facet joint on the right side.

Focal fatty changes are noted in the lumbar vertebrae.

The remaining 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 :

15.0 mm at L1-L2
12.0 mm at L2-L3
10.0 mm at L3-L4
16.0 mm at L4-L5
16.0 mm at L5-S1.

IMPRESSION :

1. Grade I spondylolisthesis of the L5 over the S1 vertebra with spondylolysis at the L5 level, bilaterally.

2. A pseudoposterior disc herniation at the L5-S1 level with a right far lateral disc herniation impinging the foraminal portion of the right L5 nerve root.
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3. Diffuse posterior disc herniations at the L3-L4 and L4-L5 levels.

4. Small posterior disc herniations at the L1-L2 and L2-L3 levels.

5. Hypertrophic facetal arthropathy at the L3-L4 and L4-L5 levels with effusion within the L3-L4 facet joint on the left side and within the L4-L5 facet joint on the right side.