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Date : 00.00.00

Name of the Patient : Abc Xyzm Salmn / M / 59 yrs.
Referred by : Dr. Abc XyzDsouza.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias since 3 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 a postero-central disc herniation indenting the traversing S1 nerve roots (right more than left) at the L5-S1 level. There appears to be slight inflammation of the traversing S1 nerve roots. The right L5-S1 facet joint shows mild hypertrophic degenerative changes.

A postero-central disc extrusion is seen to indent the thecal sac at the L4-L5 level. A disc fragment is seen to lie in the right lateral recess of L5 vertebra with resultant impingement of the traversing right L5 nerve root.

Posterior disc bulge is seen to indent the thecal sac at the L2-L3 level. Facetal hypertrophy is noted at the L2-L3, L3-L4 and L4-L5 levels.








The pedicles of the lumbar verterbae are congenitally short in their antero-posterior dimensions.

The L2-L3 to L5-S1 intervertebral discs show loss of water content.

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 S2 level.

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

13.0 mm at L1-L2

14.0 mm at L2-L3

14.0 mm at L3-L4

12.0 mm at L4-L5

10.0 mm at L5-S1.
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- 3 - Scan-00004


IMPRESSION :

The MRI features are suggestive of :

1. A postero-central disc herniation indenting the traversing S1 nerve roots (right more than left) at the L5-S1 level.

2. A postero-central disc extrusion at the L4-L5 level with a disc fragment lying in the right lateral recess of L5 vertebra with resultant impingement of the traversing right L5 nerve root.

3. Congenitally short pedicles of the lumbar verterbae in their antero-posterior dimensions.

4. Hypertrophic facetal arthropathy on the right at the L5-S1 level and facetal hypertrophy at the L2-L3, L3-L4 and L4-L5 levels.

5. Canal stenosis at the L4-L5 level.








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