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/93 Date : 00.00.00

Name of the Patient : Abc Xyza R. lmn / F / 40 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain occasionally radiating to BLE.

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 posterior disc herniation at the L5-S1 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. Far lateral (extraforaminal) disc herniations are also noted at this level with mild indentation upon the extraforaminal portion of the exiting L5 nerve roots. Ligamentum flavum hypertrophy and slight facetal arthropathy is also seen at this level.

A small posterior disc herniation is noted at the L4-L5 level with anterior indentation of the thecal sac. A posterior disc bulge is seen at the L3-L4 level.

Small bilateral far lateral (extraforaminal) disc bulges are seen at the L2-L3, L3-L4 and L4-L5 levels. A small postero-central disc herniation is seen at the L1-L2 level.

The lumbar intervertebral discs show loss of water content.

The lumbar facet joints show mild degenerative changes.


The lumbar vertebrae show areas of fatty replacement of normal marrow. 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 :

11.0 mm at L1-L2
13.0 mm at L2-L3
17.0 mm at L3-L4
19.0 mm at L4-L5
17.0 mm at L5-S1.

Note is made of small hyperintense areas in both the kidneys on the T2 Weighted images and may represent medullary cysts. Further evaluation may be worthwhile.

IMPRESSION :

1. A posterior disc herniation at the L5-S1 level.

2. Far lateral (extraforaminal) disc herniations at the L5-S1 level with mild indentation upon the extraforaminal portion of the exiting L5 nerve roots. Ligamentum flavum hypertrophy and slight facetal arthropathy is also seen at this level.

3. A small posterior disc herniation at the L4-L5 level.

4. Small bilateral far lateral (extraforaminal) disc bulges at the L2-L3, L3-L4 and L4-L5 levels.

5. A posterior disc bulge at the L3-L4 level.

6. A small postero-central disc herniation at the L1-L2 level.

7. Mild facetal arthropathy in the lumbar region.









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