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Date : 00.00.00

Name of the Patient : Abc XyzJlmn / F / 58 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE (on & off) since 3 years which has increased since 1 year.
H/O fall in 0000.

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 :

The lumbar intervertebral discs show loss of water content. Hypointense areas are seen in the L5-S1 intervertebral disc on all the pulse sequences suggestive of calcification/ vacuum phenomena.

There is a posterior disc bulge with a posterior peridiscal osteophyte and a right far lateral disc herniation at the L5-S1 level with anterior indentation of the thecal sac and right neural foraminal narrowing. There is resultant indentation upon the extraforaminal portion of the right L5 nerve root.

There is slight forward subluxation of the L4 over the L5 vertebra. A pseudoposterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. There is mild indentation on the right L4 nerve root. The L4-L5 facet joints show hypertrophic degenerative changes.

There is a small, posterior disc bulge with peridiscal osteophytes at the L3-L4 level.

Schmorls node is seen in the superior aspect of the L5 vertebra.
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The lumbar intervertebral discs show loss of water content. Hypointense areas are seen in the L5-S1 intervertebral disc on all the pulse sequences suggestive of calcification/vacuum phenomena.

The lumbar vertebral bodies show 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 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

18.0 mm at L2-L3

15.0 mm at L3-L4

11.0 mm at L4-L5

12.0 mm at L5-S1.

IMPRESSION :

1. A posterior disc bulge with a posterior peridiscal osteophyte and a right far lateral disc herniation at the L5-S1 level with resultant indentation upon the extraforaminal portion of the right L5 nerve root.

2. Slight forward subluxation of the L4 over the L5 vertebra with a pseudoposterior disc herniation at the L4-L5 level and facetal arthropathy at this level.

3. A small, posterior disc bulge with posterior peridiscal osteophyte at the L3-L4 level.


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