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Name of the Patient : Abc Xyzti A. lmn / F / 76 yrs.
Referred by : Dr. Abc Xyzlaji / Dr. Abc Xyzouni.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the LLE with paresthesias.
H/O fall of a heavy object prior to this.

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 scoliosis of the lumbar spine with convexity to the left. Sacralization of the L5 vertebra is seen and the D12 vertebral body is as marked on the film (Kindly correlate with plain radiographs). Slight retroplacement of the L1 over L2 vertebra is noted.

There is loss of water content of the lumbar intervertebral discs.

There is Grade I spondylolisthesis of the L4 over the L5 vertebral body without obvious spondylolysis. A pseudoposterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. Mild indentation upon the L5 nerve roots and the extraforaminal portion of the right L4 nerve root is noted. The facet joints at this level show hypertrophic degenerative changes with a tight canal at this level.


Small posterior disc herniations with peridiscal osteophytes are seen at the D12-L1 and L1-L2 levels with anterior indentation of the thecal sac. A left far lateral disc herniation is seen at the D12-L1 level.

The rest of the lumbar facet joints and the D9-D10 and D11-D12 appear slightly hypertrophied.

There is anterior wedging of the L1 vertebral body. Fatty changes are seen in the lower dorsal and upper lumbar vertebrae suggestive of osteoporosis.

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 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 :

12.0 mm at L1-L2
14.0 mm at L2-L3
15.0 mm at L3-L4
9.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebra (Kindly correlate with plain radiographs).

2. Grade I spondylolisthesis of the L4 over the L5 vertebral body without any obvious spondylolysis.
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3. A pseudoposterior disc herniation at the L4-L5 level with mild indentation upon the L5 nerve roots and the extraforaminal portion of the right L4 nerve root.

4. Small posterior disc herniations with peridiscal osteophytes at the D12-L1 and L1-L2 levels with a left far lateral disc herniation at the D12-L1 level.

5. Facetal hypertrophy in the lumbar region with hypertrophic facetal arthropathy at the L4-L5 level, bilaterally.

6. Anterior wedging of the L1 vertebral body may be due to previous trauma. Altered signal in the lower dorsal and upper lumbar vertebrae is suggestive of osteoporosis.


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