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ke/hs/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Plmn / M / 48 yrs.
Referred by : Dr. Abc Xyzlkaka.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

H/O injury to back by heavy object 15 days back.
C/O backache with slight radiation of pain to BLE since then.

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 mild forward listhesis of the L5 vertebra over the S1 vertebra.

A postero-central disc herniation with peridiscal osteophytes, more to the right of the midline is seen at the L5-S1 level with anterior indentation of the thecal sac and the traversing right S1 nerve root. The L5-S1 facet joints show degenerative changes.

A small postero-central disc herniation is noted at the L4-L5 level with anterior indentation of the thecal sac. A small left far lateral disc herniation is also noted at this level with mild indentation upon the extraforaminal portion of the exiting left L4 nerve root. The L4-L5 facet joints show degenerative changes.







A postero-central and left far lateral (extraforaminal) disc herniation is seen at the L3-L4 level with anterior indentation of the thecal sac and upon the extraforaminal portion of the exiting left L3 nerve root. Facetal arthropathy is also noted at this level. A small left postero-lateral (foraminal) disc herniation is seen to narrow the left neural foramen at the L3-L4 level.

Schmorls nodes are seen in the dorso-lumbar region. The D12-L1, L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content.

Small posterior peridiscal osteophytes are also seen at the L3-L4 and L4-L5 levels.

Type II degenerative changes are seen in the antero-superior portion of the L1 and L4 vertebral bodies.

The rest of 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 :

21.0 mm at L1-L2
22.0 mm at L2-L3
19.0 mm at L3-L4
16.0 mm at L4-L5
5.0 mm at L5-S1.
..3/.










- 3 - Scan-00000

IMPRESSION :

The MRI features are suggestive of :

1. Mild forward listhesis of the L5 vertebra over the S1 vertebra.

2. A postero-central disc herniation with peridiscal osteophytes, more to the right of the midline at the L5-S1 level with indentation upon the traversing right S1 nerve root.

3. A postero-central disc herniation and a small left far lateral (extraforaminal) disc herniation with mild indentation upon the extraforaminal portion of the exiting left L4 nerve root at the L4-L5 level.

4. A postero-central, small left postero-lateral (foraminal) and left far lateral (extraforaminal) disc herniation at the L3-L4 level with indentation upon the extraforaminal portion of the exiting left L3 nerve root.

5. Facetal arthropathy at the L3-L4, L4-L5 and L5-S1 levels.






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