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Date : 00.00.00

Name of the Patient : Abc Xyzhlmn / F / 37 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE (right more than left) since June 0000 with paresthesias in the RLE.

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 at the L5-S1 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. There is inferior migration of the disc fragment which is seen to lie posterior to the S1 vertebral body, minimally indenting the S1 nerve roots, more on the right. Bilateral far lateral disc bulges are also noted at this level, right more than left with slight indentation upon the L5 nerve roots. Posterior peridiscal osteophytes are also noted at this level.

A posterior and right postero-lateral disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac.

The L4-L5 and L5-S1 intervertebral discs show loss of water content.

There is slight wedging of the D12 vertebral body without any signal change.


Schmorls nodes are seen in the superior aspect of the D12 and L4 vertebral bodies. Type I degenerative change is seen in the L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral disc.

The rest of the 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.

The conus medullaris terminates at the L1-L2 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 :

17.0 mm at L1-L2
18.0 mm at L2-L3
16.0 mm at L3-L4
16.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. A postero-central disc herniation with posterior peridiscal osteophytes at the L5-S1 level with inferior migration of the disc fragment indenting the S1 nerve roots bilaterally.

2. A posterior and right postero-lateral disc herniation at the L4-L5 level.








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