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Name of the Patient : Abc Xyz J. lmn / F / 75 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 with paresthesias since 2 months.

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 vertebra and the L3 vertebra is as marked on the film.

There is loss of normal lumbar lordosis and loss of water content of the lumbar intervertebral discs. The L4-L5 intervertebral disc shows evidence of calcium/vacuum phenomena.

There is Grade I spondylolisthesis of the L3 over the L4 vertebra without obvious spondylolysis.

There is a posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level with thecal sac compression and bilateral neural foraminal narrowing. Bilateral far lateral disc bulges are also seen at this level. Slight ligamentum flavum and facetal hypertrophy is also noted at this level.
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A right paracentral disc herniation with peridiscal osteophytes is noted at the L3-L4 level with right neural foraminal narrowing. Hypertrophic facetal arthropathy and ligamentum flavum hypertrophy is noted at this level.

A posteriorly bulging disc with peridiscal osteophytes is seen at the L2-L3 level with slight facetal hypertrophy at this level.

The lumbar vertebral bodies show spotty fatty marrow changes. The rest of the 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 S1-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
12.0 mm at L2-L3
6.0 mm at L3-L4
9.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebra.

2. Grade I spondylolisthesis of the L3 over the L4 vertebra without obvious spondylolysis.

3. A posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level with slight ligamentum flavum and facetal hypertrophy at this level.
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4. A right paracentral disc herniation with peridiscal osteophytes at the L3-L4 level with hypertrophic facetal arthropathy and ligamentum flavum hypertrophy at this level.

5. A posteriorly bulging disc with peridiscal osteophytes at the L2-L3 level with slight facetal hypertrophy at this level.

6. Lumbar canal stenosis at L3-L4, L4-L5 and L5-S1 levels.


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