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ke/sb/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzam Ylmn / M / 44 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

H/O fall 7-8 years back followed with pain in the RLE.
C/O radicular pain to the RLE with tingling in the sole.

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 right postero-lateral disc herniation with peridiscal osteophytes at the L5-S1 level with indentation on the right S1 nerve root and right neural foraminal narrowing. There is a sequestered disc fragment in the right lateral recess at S1. There is also a suggestion of inflammation of the right S1 nerve root.

A diffuse posterior disc herniation with peridiscal osteophytes is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. Mild facetal arthropathy and ligamentum flavum hypertrophy is noted at this level with resultant canal stenosis.

Small left far lateral disc bulge is noted at the L3-L4 level. The L4-L5 and L5-S1 intervertebral discs show loss of water content.



Subtle hypointense signal is seen in the S1 vertebral body on the T1 Weighted images adjacent to its superior cortical endplate and is heterogeneously hypointense on the T2 Weighted images and would represent Type I/III degenerative changes.

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 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 :

16.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
13.0 mm at L4-L5
8.0 mm at L5-S1.

Screening, T2 Weighted sagittal images of the dorsal spine do not show any significant feature of note.

IMPRESSION :

1. A right postero-lateral disc herniation with peridiscal osteophytes at the L5-S1 level with indentation on the right S1 nerve root. There is a suggestion of inflammation of the right S1 nerve root. A sequestered disc fragment is noted in the right lateral recess of S1 vertebra.

2. A diffuse posterior disc herniation with peridiscal osteophytes at the L4-L5 level with mild facetal arthropathy and ligamentum flavum hypertrophy at this level with resultant canal stenosis.

3. Small left far lateral disc bulge at the L3-L4 level.






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