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sb/bv/rg.

Name of the Patient : Abc Xyz Dslmn / F / 54 yrs.
Referred by : Dr. Abc Xyzauhan.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with numbness in the RLE.
H/O L4-L5 laminectomy done in 0000.

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 nearly all the lumbar intervertebral discs except the L1-L2 disc.

There is evidence of laminectomy at the L5 vertebral level and partial laminectomy at L4 with post-operative changes in the soft tissues in the posterior lumbar region at this level.

There is Grade I spondylolisthesis of the L4 over the L5 vertebra with a pseudo-posterior disc bulge at this level, more to the right of the midline. Hypertrophic facetal arthropathy is noted at this level with facet joint effusion. An intermediate signal on the T1 Weighted images is noted around the traversing right L5 nerve root in the right lateral recess of L5. This may represent scar tissue and is less likely to represent a sequestered disc fragment (scans 104.4-5).

A small right paracentral protruded disc is noted at the L5-S1 level with facetal hypertrophy at that level.
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A minimal posterior disc bulge is noted at the L3-L4 level with slight facetal hypertrophy at that level.

Slight facetal hypertrophy is also noted at the L1-L2 and L2-L3 levels.

The lumbar vertebral bodies 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 :

19.0 mm at L1-L2
18.0 mm at L2-L3
16.0 mm at L3-L4

IMPRESSION :

1. Post-operative status.

2. Grade I spondylolisthesis of the L4 over the L5 vertebra with a pseudo-posterior disc bulge at this level, more to the right of the midline with hypertrophic facetal arthropathy and with facet joint effusion at this level.

3. Altered signal around the traversing right L5 nerve root in the right lateral recess of L5 may represent scar tissue (less likely to represent a sequestered disc fragment).

4. A small right paracentral protruded disc at the L5-S1 level with facetal hypertrophy at that level.

As compared to the previous MRI (Study No.0000) dated 00.00.0000, the patient is status post-operative. There is slight increase in the degree of forward translation of the L4 vertebra over the L5 vertebra with slight increase in the degree of the bulging disc at the L4-L5 level.
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