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bv/sb/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzi Shlmn / F / 45 yrs.
Referred by : Dr. Abc Xyzar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to RUE and RLE with paresthesias since 2 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 appears to be partial sacralization of the L5 vertebra on the left side.

There is Grade II spondylolisthesis of L4 over the L5 vertebra with spondylolysis at the L4 level bilaterally.

Type II (fatty changes)/ Type III (sclerosis) degenerative marrow changes are seen adjacent to the L4-L5 disc in the L4 and L5 vertebral bodies, respectively.

A pseudo-posterior disc herniation is seen at the L4-L5 level with narrowing of the right neural foramen. The facet joints at the L4-L5 level show gross hypertrophic changes.

A posterior peridiscal osteophyte is seen to arise from the posterior superior margin of L5 vertebra with ventral indentation upon the thecal sac.

A small posterior disc bulge is identified at the L5-S1 level.
..2/.







The right facet joint at the L3-L4 level appears slightly hypertrophied.

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

The conus medullaris terminates at the D12 level and the thecal sac terminates at the L5-S1 level.

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

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

Screening of the dorsal spine shows no significant feature of note. Early degenerative changes are seen in the cervical spine over the C3-C4 to C6-C7 levels.

IMPRESSION :

The MRI features are suggestive of :

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

2. Grade II spondylolisthesis of L4 over the L5 vertebra with spondylolysis at the L4 level bilaterally.

3. A pseudo-posterior disc herniation at the L4-L5 level with
gross facetal hypertrophy at this level.

4. A posterior peridiscal osteophyte arising from the posterior superior margin of L5.

5. A small posterior disc bulge at the L5-S1 level.








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