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ke/sb/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzyam Sollmn / M / 38 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE with paresthesias.
H/O fall 1 month back.

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 sacralization of the L5 vertebral body and the L2 vertebra is as marked on the film.

There is forward listhesis of the L4 over the L5 vertebral body with bilateral spondylolysis of the L4 vertebra.

A large pseudoposterior and right postero-lateral disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac. There is superior migration of the disc posterior to the L5 vertebral body with impingement of the right L4 nerve root. Bilateral far lateral disc herniations are also noted at this level with indentation upon the foraminal and extraforaminal portion of the L4 nerve root on the right side and the extraforaminal portion of the left L4 nerve root. The L4-L5 disc show loss of water content.

The L2-L3, L3-L4 and L5-S1 facet joints show degenerative changes with hypertrophic changes at the L4-L5 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.

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
14.0 mm at L3-L4
12.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebral body.

2. Forward listhesis of the L4 over the L5 vertebral body with bilateral spondylolysis of the L4 vertebra.

3. A large pseudoposterior and right postero-lateral disc herniation at the L4-L5 level with superior migration of the disc posterior to the L5 vertebral body impinging the right L4 nerve root. Bilateral far lateral disc herniations are also noted at this level with indentation upon the foraminal and extraforaminal portion of the L4 nerve root on the right side and the extraforaminal portion of the left L4 nerve root.

4. Facetal arthropathy at the L2-L3, L3-L4 and L5-S1 levels and gross hypertrophic changes at the L4-L5 level.



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