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Date : 00.00.00

Name of the Patient : Abc XyzO.T. Dslmn / F / 31 yrs.
Referred by : Dr. Abc XyzShah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with numbness in the LLE since 00.00.00.

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 L1 vertebral body is as marked on the film.

A large left paracentral and left far lateral disc herniation is seen at the L4-L5 level with anterior compression of the thecal sac and bilateral neural foraminal narrowing, left more than right. A disc fragment is seen to migrate inferiorly in the left lateral recess of L5 vertebra with impingement of the traversing left L5 nerve root. A small disc portion is also seen to migrate superiorly in the left lateral recess of L4 vertebra. There is mild indentation upon the exiting left L4 nerve root at the L4-L5 level. The right L5 nerve root appears thickened ? inflamed.

A posterior disc herniation is seen at the L3-L4 level with anterior indentation of the thecal sac.

The L3-L4 , L4-L5 and L5-S1 intervertebral discs show loss of water content.

Type II degenerative changes are noted in the postero-superior aspect of the L5 vertebra.

The rest of the lumbar vertebral bodies and the remaining intervertebral discs show normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus modularize terminates at the D11-D12 level and the theca sac terminates at the S1 level.
..2/.




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The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

24.0 mm at L1-L2

18.0 mm at L2-L3

14.0 mm at L3-L4

10.0 mm at L4-L5

5.0 mm at L5-S1

IMPRESSION :

1. Sacralization of the L5 vertebra.

2. A large left paracentral and left far lateral disc herniation at the L4-L5 level with a disc fragment migrating inferiorly in the left lateral recess of L5 vertebra impinging the traversing left L5 nerve root with a small disc portion seen to migrate superiorly in the left lateral recess of L4 vertebra. There is mild indentation upon the exiting left L4 nerve root at the L4-L5 level. The right L5 nerve root appears thickened ? inflamed.

3. A posterior disc herniation at the L3-L4 level.


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