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sb/hs/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzan Jlmn / M / 73 yrs.
Referred by : Dr. Abc Xyzcha.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain in the RLE with tingling since 8 days.

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 and it is as marked on the film.

There is loss of water content of all the lumbar intervertebral discs.

There is a postero-central and right postero-lateral disc herniation at the L4-L5 level with right neural foraminal narrowing. A sequestered disc fragment is noted in the right lateral recess of the L5 vertebra and indenting the traversing right L5 nerve root. Ligamentum flavum hypertrophy is noted at the L4-L5 and L5 levels. The L4-L5 facet joints show hypertrophic degenerative changes.

A small posterior disc bulge is noted at the L3-L4 level. A small right postero-lateral disc herniation is seen to narrow the right neural foramen at the L3-L4 level.
Scan-00003

Right far lateral (exrtraforaminal) disc herniations are seen to indent the extraforaminal portion of the exiting right L3 and L4 nerve roots at the L3-L4 and L4-L5 levels, respectively.

The remaining lumbar vertebral bodies show fatty marrow changes. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12-L1 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
17.0 mm at L2-L3
16.0 mm at L3-L4
13.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebra.

2. A postero-central and right postero-lateral disc herniation at the L4-L5 level with a sequestered disc fragment in the right lateral recess of the L5 vertebra and indenting the traversing right L5 nerve root.

3. Ligamentum flavum hypertrophy at the L4-L5 and L5 levels and hypertrophic facetal arthropathy at the L4-L5 level.

4. Right far lateral (extraforaminal) disc herniations indenting the extraforaminal portion of the exiting right L3 and L4 nerve roots at the L3-L4 and L4-L5 levels respectively.

5. A small right postero-lateral disc herniation at the L3-L4 level.








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