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sb/bv
Date : 26.0000

Name of the Patient : Abc Xyzeer Grlmn / F / 52 yrs.
Referred by : Dr. Abc Xyzain.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with burning sensation and paresthesias since 2 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 D11-D12, L3-L4, L4-L5 and L5-S1 intervertebral discs.

A postero-central disc herniation is noted at the L5-S1 level with slight inferior migration of the disc fragment. Facetal hypertrophy is noted at this level. The right S1 nerve root appears to be of slightly larger calibre and is ? inflammed. There is also posterior displacement of the left S1 nerve root.

A posterior disc bulge with a right postero-lateral (foraminal) disc herniation is seen at the L4-L5 level with right neural foraminal narrowing. A posterior peridiscal osteophyte is also noted at this level. Slight facetal hypertrophy is also identified. There is resultant pinching of the foraminal portion of the right L4 nerve root.

A minimal posterior disc bulge is noted at the L3-L4 level.

A small right paracentral protruded disc is noted at the D11-D12 level. Facetal arthropathy is also noted at this level.

Anterior disc herniations are seen at the L3-L4 and L4-L5 levels.

A hemangioma with fat content is noted in the L3 vertebral body to the left of the midline.
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The rest of the lumbar vertebral bodies and the remaining intervertebral discs 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 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

13.0 mm at L3-L4

10.0 mm at L4-L5

10.0 mm at L5-S1.

IMPRESSION :

1. A postero-central disc herniation at the L5-S1 level with slight inferior migration of the disc fragment with indentation upon the S1 nerve roots with facetal hypertrophy at this level.

2. A posterior disc bulge with a right postero-lateral (foraminal) disc herniation at the L4-L5 level. Posterior peridiscal osteophyte and slight facetal hypertrophy is also identified at this level with resultant impingement on the right foraminal L4 nerve root.

3. A small right paracentral protruded disc at the D11-D12 level with facetal arthropathy at this level.

4. Lumbar canal stenosis at the L4-L5 and L5-S1 levels.
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