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Date : 00.00.00

Name of the Patient : Abc Xyza Kalmn / F / 70 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain to the RLE since 2 months with paresthesias.

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 L3-L4, L4-L5 and L5-S1 intervertebral discs and loss of water content of these lumbar intervertebral discs.

There is scoliosis of the lumbar spine with convexity to the right with lateral subluxation of the L4 over the L5 vertebra with peridiscal osteophytes.

There is retroplacement of the L5 vertebra over the S1 vertebra and slight forward translation of the L4 over the L5 and L3 over L4 vertebrae.

There is a posteriorly herniated disc with posterior peridiscal osteophyte at the L5-S1 level with indentaion on the S1 nerve roots bilaterally. Right far lateral disc herniation with peridiscal osteophyte is also noted with right neural foraminal narrowing and indentation on the extraforaminal segment of the right L5 nerve root.


A left postero-lateral and left far lateral disc herniation with peridiscal osteophytes is noted at the L4-L5 level with indentation on the left L5 nerve root, left neural foraminal narrowing and impingement of the the foraminal segment of the left L4 nerve root.

A left postero-lateral disc herniation with peridiscal osteophyte is ntoed at the L3-L4 level with left neural foraminal narrowing.

Hypertrophic facetal arthropathy and ligamentum flavum hypertrophy is noted at the L3-L4, L4-L5 and L5-S1 levels bilaterally with canal stenosis.

Anterior disc herniations with anterior peridiscal osteophytes is noted in the lower lumbar region.

Type II degenerative marrow changes are noted adjacent to the L4-L5 disc.

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

The conus medullaris terminates at the L1-L2 level and the thecal sac terminates at the S1-S2 level.

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

17.0 mm at L1-L2
20.0 mm at L2-L3
12.0 mm at L3-L4
11.0 mm at L4-L5
11.0 mm at L5-S1.
..3/.







- 3 - scan-00003

IMPRESSION :

The MRI features suggest gross degenerative changes in the lumbar spine with :

1. Scoliosis of the lumbar spine with convexity to the right side and lateral subluxation of the L4 over L5 vertebra with peridiscal osteophytes.

2. Retroplacement of the L5 vertebra over the S1 vertebra and slight forward translation of the L4 over the L5 and L3 over L4 vertebrae.

2. A posteriorly herniated disc with posterior peridiscal osteophyte at the L5-S1 level with indentaion on the S1 nerve roots bilaterally with right far lateral disc herniation with peridiscal osteophyte with right neural foraminal narrowing and indentation on the extraforaminal segment of the right L5 nerve root at this level.

3. A left postero-lateral and left far lateral disc herniation with peridiscal osteophytes at the L4-L5 level with indentation on the left L5 nerve root.

4. A left postero-lateral disc herniation with peridiscal osteophyte at the L3-L4 level with left neural foraminal narrowing.

6. Hypertrophic facetal arthropathy and ligamentum flavum hypertrophy at the L3-L4, L4-L5 and L5-S1 levels bilaterally with canal stenosis.






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