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Date : 00.00.00
sb/hs
Name of the Patient : Abc Xyzam R. Jalmn / M / 65 yrs.
Referred by : Dr. Abc Xyzrges.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE with paresthesias since 3-4 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 reduction in height of the L5-S1 disc and loss of water content of the lumbar intervertebral discs.

Posterior peridiscal osteophytes are noted at the L5-S1 level with right neural foraminal narrowing and impingement of the foraminal segment of the exiting right L5 nerve root and on the traversing right S1 nerve root (scans 103.6, 105.2).

A posteriorly herniated disc is noted at the L4-L5 level with bilateral neural foraminal narrowing and indentation on the traversing left L5 nerve root . A left far lateral (extraforaminal) disc bulge is also noted at this level.

Right far lateral (extraforaminal) disc herniations are seen to indent the extraforaminal portion of the exiting right L4 and L5 nerve roots at the L4-L5 and L5-S1 levels, respectively.

A small posterior and right far lateral disc bulge is noted at the L3-L4 level.

A small posteior disc herniation with peridiscal osteophytes is noted at the L2-L3 level with bilateral neural foraminal narrowing.

A right postero-lateral and right far lateral (extraforaminal) disc bulge is noted at the L1-L2 level, with right neural foraminal narrowing.
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Type II degenerative marrow changes are noted adjacent to the L5-S1 disc.

The facet joints at the L4-L5 and L5-S1 levels show hypertrophic degenerative changes. Facetal hypertrophy is seen at the L3-L4 level.

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

Incidental note is made of fat in the filum terminale at the L2 and L3 vertebral levels.

The conus medullaris terminates at the 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 :

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

IMPRESSION :

1. Posterior peridiscal osteophytes at the L5-S1 level with right neural foraminal narrowing and indentation upon the foraminal segment of the exiting right L5 nerve root.

2. A posteriorly herniated disc at the L4-L5 level with bilateral neural foraminal narrowing and indentation on the traversing left L5 nerve root.

3. A small posterior disc herniation with peridiscal osteophytes at the L2-L3 level.

4. Right far lateral (extraforaminal) disc herniations indenting the extraforaminal portion of the exiting right L4 and L5 nerve roots at the L4-L5 and L5-S1 levels, respectively.

5. Hypertrophic facetal arthropathy at the L4-L5 and L5-S1 levels.




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