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Date : 00.00.00

Name of the Patient : Abc Xyz S. Wlmn / M / 36 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Dorso-lumbar Spine.

CLINICAL PROFILE :

C/O weakness of BLE (right more than left) since 3 months.

EXAMINATION :

M.R.I of the dorso-lumbar 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.

The cervical spine was screened with 5 mm thick T1 Weighted and T2 Weighted sagittal images and 5 mm thick T1 Weighted and Fast Scan (T2 *) axial images.

OBSERVATION :

There is loss of water content of the L4-L5 intervertebral disc.

A posterior disc herniation is noted at the L4-L5 level with bilateral neural foraminal narrowing. Mild ligamentum flavum hypertrophy is seen at this level.

Slight anterior wedging of the D11 and D12 vertebral bodies is noted, with fatty marrow changes, which may be the sequelae of previous trauma.

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

- 2 - Scan - 00008

The visualized dorsal spinal cord reveals normal signal intensity.

The conus medullaris terminates at the L1 level.

Screening images of the cervical spine reveal loss of water content of the cervical intervertebral discs.

Postero-central disc herniations are noted at the C4-C5 and C6-C7 levels, indenting the cervical spinal cord anteriorly.

A fairly large, posteriorly herniated disc with posterior peridiscal osteophytes is noted at the C5-C6 level with cord compression. The cervical spinal cord at this level shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images suggesting cord edema/ischemia.

Screening images of the upper dorsal region reveal slight central wedging of the D4, D5 and D8 vertebral bodies without change in their signal intensity.

IMPRESSION :

1. Degenerated L4-L5 disc with a posterior disc herniation at this level.

2. Postero-central disc herniations at the C4-C5 and C6-C7 levels.

3. A fairly large, posteriorly herniated disc with peridiscal osteophytes at the C5-C6 level, with cord compression.

4. Altered cord signal at the C5-C6 level suggests cord edema/ischemia.

5. Wedging of the D4, D5, D8, D11 and D12 vertebral bodies (may be the sequelae of previous trauma).

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