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Name of the Patient : Abc Xyzedali M. Klmn / M / 61 yrs.
Referred by : Dr. Abc Xyztchha.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE with paresthesias.

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 with reduction in height of the L4-L5 intervertebral disc.

There is Grade I spondylolisthesis of the L4 over the L5 vertebra with spondylolysis at L4 bilaterally and compromise of the neural foramen bilaterally at this level. There is resultant pseudoposterior and left postero-lateral disc herniation at the L4-L5 level with left neural foraminal narrowing. A part of the disc fragment is noted in the left neural foramen at the L4-L5 level indenting the left L4 nerve root. Ligamentum flavum hypertrophy is also seen at this level. Type I degenerative marrow changes are noted adjacent to the L4-L5 disc.

A small postero-central and left paracentral disc herniation is noted at the L5-S1 level with slight indentation of the traversing left S1 nerve root. Baggy nerve sheath is seen at the S1 level on the left side. Slight facetal hypertrophy is noted at this level.
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The rest of the lumbar vertebral bodies show slight spotty fatty marrow changes. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1-L2 level and the thecal sac terminates at the S2 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
11.0 mm at L4-L5
9.0 mm at L5-S1.

IMPRESSION :

1. Grade I spondylolisthesis of the L4 over the L5 vertebra with spondylolysis at L4 bilaterally.

2. A pseudoposterior and left postero-lateral disc herniation at the L4-L5 level with left neural foraminal narrowing with a part of the disc fragment in the left neural foramen at the L4-L5 level indenting the left L4 nerve root.

3. A small postero-central and left paracentral disc herniation at the L5-S1 level with slight indentation of the traversing left S1 nerve root and slight facetal hypertrophy at this level.

4. A tight lumbar canal at the L4-L5 level.
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