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sb/ke
Date : 00.00.00

Name of the Patient : Abc XyzJlmn / F / 49 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 2-3 months.

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 L4-L5 and L5-S1 intervertebral discs.

There is Grade I spondylolisthesis of the L4 over the L5 vertebra without obvious spondylolysis. Resultant pseudo-posterior disc bulge is noted at the L4-L5 level. There is also hypertrophic facetal arthropathy and compromise of the neural foramen, bilaterally at this level. Facet joint effusion is noted at the L4-L5 level bilaterally.

A small postero-central protruded disc is noted at the L5-S1 level.

The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
Scan-00006


The conus medullaris terminates at the D12-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 :

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

IMPRESSION :

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

2. A pseudo-posterior disc bulge at the L4-L5 level with hypertrophic facetal arthropathy and compromise of the neural foramen, bilaterally at this level. Facet joint effusion is noted at the L4-L5 level bilaterally.









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    • Interventional Pain Procedure Templates
    • The Ultimate Guide to Rapid Reporting for FRCR 2B
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