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Date : 00.00.00

Name of the Patient : Abc XyzPawalmn / M / 70 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias since 2 years.
H/O fall many years ago.

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 except the L5-S1 disc. The L4-L5 disc shows evidence of calcium/vacuum phenomena.

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

Slight retroplacement of the L3 over the L4 and L2 over L3 vertebrae is noted.

A left far lateral protruded disc is noted at the L5-S1 level.

A generalized posteriorly herniated disc is noted at the L4-L5 level with bilateral neural foraminal narrowing. There is also facetal and ligamentum flavum hypertrophy with resultant canal stenosis.

Posterior and bilateral far lateral disc bulges with peridiscal osteophytes are noted at the L3-L4 level with bilateral neural foraminal narrowing. Facetal and ligamentum flavum hypertrophy with canal stenosis is also noted.

A small posterior disc bulge with small peridiscal osteophytes is noted at the L2-L3 level.
....2/.







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Small postero-central protruded disc is noted at the L1-L2 level.

A postero-central disc herniation is noted at the D12-L1 level indenting the dural theca anteriorly. Slight superior migration of the disc fragment is seen.

Schmorls node is noted in the L3 vertebral body.

Type II degenerative marrow changes are noted adjacent to the lower lumbar intervertebral discs, anteriorly.

The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the 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 :

6.0 mm at D12-L1

10.0 mm at L1-L2

10.0 mm at L2-L3

12.0 mm at L3-L4

8.0 mm at L4-L5

7.0 mm at L5-S1.

IMPRESSION :

1. Grade I spondylolisthesis of the L4 over the L5 vertebra without obvious spondylolysis.
...3/..










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2. Slight retroplacement of the L3 over the L4 and L2 over L3 vertebrae.

3. A generalized posteriorly herniated disc at the L4-L5 level with facetal and ligamentum flavum hypertrophy with resultant canal stenosis.

4. Posterior and bilateral far lateral disc bulges with peridiscal osteophytes at the L3-L4 level with facetal and ligamentum flavum hypertrophy with canal stenosis.

5. A small posterior disc bulge with small peridiscal osteophytes at the L2-L3 level.

6. A postero-central disc herniation at the D12-L1 level with slight superior migration of the disc fragment.




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