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sb/hs
Date : 00.00.00

Name of the Patient : Abc lmn / M / 36 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with paresthesias since 8 years.

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 sacralization of the L5 vertebra which is as marked on the film. The posterior part of the L5-S1 intervertebral disc is obliterated with fusion of the L5 and S1 vertebral bodies in that region.

There is loss of normal lumbar lordosis and loss of water content of the L3-L4 and L4-L5 intervertebral discs. Slight retroplacement of the L4 vertebra over the L5 vertebra is noted.

There is a fairly large, postero-central and right paracentral extruded disc at the L4-L5 level with thecal sac compression. Superior migration of the disc fragment is noted, displacing the thecal sac to the left and indenting the traversing right L4 nerve root. There is also slight inferior migration of the disc fragment to the right of the midline indenting the traversing right L5 nerve root. Facetal hypertrophy is noted at the L4-L5 level.
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Bilateral (extraforaminal) disc bulges are noted at the L4-L5 level.

A postero-central and right postero-lateral (foraminal) protruded discs are noted at the L3-L4 level. Mild facetal hypertrophy is seen at this level.

Type II degenerative marrow changes are noted adjacent to the L4-L5 and L3-L4 discs. A hemangioma with fat content is noted in the L1 vertebral body.

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 D12 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 D12-L1

17.0 mm at L1-L2

16.0 mm at L2-L3

14.0 mm at L3-L4

7.0 mm at L4-L5

IMPRESSION :

1. Sacralization of the L5 vertebra which is as marked on the film.
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2. A fairly large, postero-central and right paracentral extruded disc at the L4-L5 level with superior migration of the disc fragment, displacing the thecal sac to the left and indenting the traversing right L4 nerve root. Slight inferior migration of the disc fragment to the right of the midline is also noted indenting the traversing right L5 nerve root. Facetal hypertrophy is noted at the L4-L5 level.

3. Postero-central and right postero-lateral protruded discs at the L3-L4 level.

4. Canal stenosis at the L4-L5 level.





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