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ke/bv/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzi Barodalmn / M / 52 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE.

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 over the L5 vertebral body without any obvious spondylolysis. Slight retrolisthesis of the L3 over the L4 vertebra is noted.

The L1-L2, L3-L4 and L4-L5 intervertebral discs show loss of water content.

A large posterior disc herniation is seen at the L4-L5 level with anterior compression of the thecal sac and canal stenosis. Bilateral far lateral disc bulges are also noted at this level with bilateral neural foraminal narrowing and mild indentation upon the L4 nerve roots. The L4-L5 facet joints show hypertrophic degenerative changes.

A pseudoposterior disc herniation is seen at the L3-L4 level with anterior indentation of the thecal sac. The L3-L4 facet joints show degenerative changes with effusion bilaterally.

Sclerosis is noted in the left postero-inferior aspect of the L1 vertebral body.
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Ligamentum flavum hypertrophy is seen at the L4-L5 and L5 levels.

The rest of 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 D11-D12 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 :

12.0 mm at L1-L2
14.0 mm at L2-L3
10.0 mm at L3-L4
6.0 mm at L4-L5
7.0 mm at L5-S1.

IMPRESSION :

1. Grade I spondylolisthesis of the L4 over the L5 vertebral body without any obvious spondylolysis and slight retrolisthesis of the L3 over the L4 vertebra.

2. A large posterior disc herniation at the L4-L5 level and bilateral far lateral disc bulges at this level indenting upon the L4 nerve roots with hypertrophic facetal arthropathy at this level.

3. A pseudoposterior disc herniation at the L3-L4 level with facetal arthropathy and effusion within the facet joints.

4. Canal stenosis at the L3-L4 and L4-L5 levels.

As compared to the previous MRI (study no:00005) dated 00.00.00, the L4-L5 disc herniation appears slightly increased. The L3-L4 disc appears nearly unchanged.

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