sb/ke/rg.

Name of the Patient : Abc Xyztala Relmn / F / 52 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE since 6-7 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 loss of water content of the lumbar intervertebral discs. The L4-L5 and L5-S1 intervertebral discs show evidence of calcium/vacuum phenomena.

There is Grade I spondylolisthesis of the L4 over the L5 vertebra with spondylolysis at L4, bilaterally and compromise of the neural foramina at the L4-L5 level bilaterally.

There is a resultant pseudo-posterior disc bulge with peridiscal osteophytes at the L4-L5 level with bilateral neural foraminal narrowing and impingement of the L4 nerve roots in the neural foramen at the L4-L5 level bilaterally. There is also slight facetal hypertrophy with canal stenosis.

A posteriorly bulging disc with peridiscal osteophytes is noted at the L5-S1 level with bilateral neural foraminal narrowing and slight facetal hypertrophy at this level.
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Left and right postero-lateral disc bulges are noted at the L2-L3 and L3-L4 levels with slight facetal hypertrophy and corresponding neural foramen narrowing.

The L5 vertebral body is slightly wedged anteriorly and the L4 and L5 vertebral bodies show spotty fatty marrow changes.

The rest of 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 L1-L2 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 :

16.0 mm at L1-L2
15.0 mm at L2-L3
14.0 mm at L3-L4
12.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. Grade I spondylolisthesis of the L4 over the L5 vertebra with spondylolysis at L4, bilaterally and compromise of the neural foramina at the L4-L5 level bilaterally.

2. A pseudo-posterior disc bulge with peridiscal osteophytes at the L4-L5 level with impingement of the L4 nerve roots in the neural foramen at the L4-L5 level bilaterally and slight facetal hypertrophy with canal stenosis at this level.

3. A posteriorly bulging disc with peridiscal osteophytes at the L5-S1 level with slight facetal hypertrophy at this level.

4. Left and right postero-lateral disc bulges at the L2-L3 and L3-L4 levels with slight facetal hypertrophy.