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hs/bv
Date : 00.00.00

Name of the Patient : Abc Xyzam Tamhalmn / M / 48 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with radiation of pain to BLE 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 :

The lumbar intervertebral discs except at the L5-S1 level show loss of water content. There is loss of normal lumbar lordosis.

A large posterior disc extrusion, more to the left of the midline is seen to compress upon the thecal sac and narrow both neural foramina at the L3-L4 level.

A posterior disc herniation is seen to indent the thecal sac and narrow both neural foramen at the L4-L5 level.

A small postero-central disc protrusion is seen at the L2-L3 level.

Bilateral far lateral (extraforaminal) disc herniations are noted over the L1-L2 to L4-L5 levels.

There are posterior disc bulges at the L1-L2 and L5-S1 levels.

The pedicles of the lumbar vertebrae are congenitally short in their antero-posterior dimensions.
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A hemangioma with high fat content (hyperintense on all the pulse sequences) is seen within the D12 vertebral body on the right side.

A probable conjoint nerve root is noted on the left side at the L5-S1 level. Also seen is a small Tarlovs cyst on the right side at the S2 level.

The lumbar vertebral bodies reveal normal signal intensity. 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 :

12.0 mm at L1-L2
11.0 mm at L2-L3
10.0 mm at L3-L4
11.0 mm at L4-L5
13.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. A large posterior disc extrusion, more to the left of the midline with canal stenosis at the L3-L4 level.

2. A posterior disc herniation at the L4-L5 level.

3. A small postero-central disc protrusion at the L2-L3 level.

4. Tight lumbar canal at the L3-L4 and L4-L5 levels.

5. Congenitally short pedicles of the lumbar vertebrae in their antero-posterior dimensions.





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