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hs/ke/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzed Sabir lmn / M / 62 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 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 L4 vertebra over the L5 vertebra.

A posterior disc herniation is seen to indent the thecal sac at the L4-L5 level and narrow both neural foramina bilaterally at this level. Bilateral far lateral (extraforaminal) disc herniations are seen to indent the extraforaminal portion of the exiting L4 nerve roots at the L4-L5 level.

A posterior disc bulge is seen to indent the thecal sac and narrow both neural foramina at the L5-S1 level.

Bilateral far lateral (extraforaminal) disc bulges are noted at the L2-L3, L3-L4 and L5-S1 levels.

The L4-L5 facet joints show hypertrophic degenerative changes. The L5-S1 facet joints show degenerative changes. There is ligamentum flavum hypertrophy at the L4-L5 level.
Scan-00002


The lumbar intervertebral discs show loss of water content.

The lumbar vertebral bodies reveal normal signal intensity. 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 S2 level.

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

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

IMPRESSION :

The MRI features are suggestive of :

1. Grade I spondylolisthesis of the L4 vertebra over the L5 vertebra.

2. A posterior disc herniation, hypertrophic facetal arthropathy and ligamentum flavum hypertrophy with canal stenosis at the L4-L5 level.

3. Posterior disc bulge and facetal arthropathy at the L5-S1 level.

4. Bilateral far lateral (extraforaminal) disc herniations at the L4-L5 level.

5. A tight canal at the L5-S1 level.








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