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Name of the Patient : Abc XyzRenuka Galmn / F / 52 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE with numbness since 15 days.
H/O laminectomy at the L5-S1 level with bone grafting 10 years ago.

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 the lumbar intervertebral discs. The L5 vertebra is sacralized.

There is laminectomy of the L5 and S1 vertebrae with post-operative changes in soft tissues in the posterior lumbar region at these levels. There is evidence of intertransverse bone grafting at L5-S1 level.

There is Grade I spondylolisthesis of the L5 over the S1 vertebra. It is difficult to assess for spondylolysis, due to bone grafting. A posterior peridiscal osteophyte is noted at the L5-S1 level. The intertransverse bone grafts are seen to encroach into the spinal canal at the L5-S1 level, with some new bone formation. The intrathecal nerve roots at the L5-S1 level clumped centrally which may suggests Group III arachnoiditis. There is pinching of the foraminal portion of the L5 nerve roots bilaterally (left more than right).
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A small, posterior disc bulge is noted at the L4-L5 level with hypertrophic facetal arthropathy and facet joints effusion at this level.

Anterior peridiscal osteophytes are seen in the lower dorsal region more to the right of the midline.

Slight facetal hypertrophy is also noted at the L2-L3 and L3-L4 levels.

A small right paracentral protruded disc is noted at the D12-L1 level.

Type II degenerative marrow changes are noted adjacent to the L5-S1 intervertebral disc.

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

The conus medullaris terminates at the 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 :

20.0 mm at L1-L2
13.0 mm at L2-L3
11.0 mm at L3-L4
15.0 mm at L4-L5

IMPRESSION :

1. Post-operative status.

2. Sacralized L5 vertebra.
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3. Grade I spondylolisthesis of the L5 over the S1 vertebra with a posterior peridiscal osteophyte at that level. Encroachment into the spinal canal at the
L5-S1 level by the intertransverse bone grafts is noted with pinching of the foraminal portion of the L5 nerve roots.

4. Group III arachnoiditis at the L5-S1 level.

5. A small, posterior disc bulge at the L4-L5 level with hypertrophic facetal arthropathy.

6. Slight facetal hypertrophy at the L2-L3 and L3-L4 levels.


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