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Date : 00.00.00

Name of the Patient : Abc XyzManglmn / M / 69 yrs.
Referred by : Dr. Abc Xyzah / Dr. Abc XyzDoshi.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O heaviness of the LLE since 4-5 months.
H/O lumbar laminectomy in February 0000.

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 evidence of laminectomy of the L2, L3 and L4 vertebrae with post-operative changes within the posterior soft tissues over these levels.

There is slight loss of water content of all the lumbar intervertebral discs. Some of the lumbar discs are reduced in height and show evidence of calcium/vacuum phenomena. There is slight retrolisthesis of the L2 over the L3 vertebrae.There is a posterior disc herniation and a left postero-lateral (foraminal) disc herniation at the L5-S1 level with left neural foraminal narrowing. A part of the disc fragment is noted in the left lateral recess of S1, indenting the traversing left S1 nerve root. There are also hypertrophic degenerative changes of the facet joints at the L5-S1 level.Posteriorly bulging discs with posterior peridiscal osteophytes are noted at the L2-L3 and L3-L4 levels. The L3-L4 facet joints show degenerative changes. ..2/.





- 2 - scan-00007
A small posterior disc herniation with peridiscal osteophyte is noted at the L4-L5 level. Hypertrophic facetal arthropathy and ligamentum flavum hypertrophy is also noted at this level. There is mild bilateral neural foraminal narrowng at the L4-L5 level.
The intrathecal nerve roots over the L2 to L4 levels are thickened and irregularly defined and this would suggest Group I arachnoiditis.
Slight anterior wedging of the D11, D12 and L1 vertebral bodies is noted without change in signal intensity. The lumbar vertebral bodies reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
IMPRESSION :
1. Post-operative status.

2. Slight retrolisthesis of the L2 over the L3 vertebrae. 3. A posterior disc herniation and a left postero-lateral (foraminal) disc herniation at the L5-S1 level with left neural foraminal narrowing with a part of the disc fragment in the left lateral recess of S1, indenting the traversing left S1 nerve root with hypertrophic facetal arthropathy at this level.4. A small posterior disc herniation with posterior peridiscal osteophytes at the L4-L5 level. Hypertrophic facetal arthropathy and ligamentum flavum hypertrophy is also seen at this level.

5. Posteriorly bulging discs with posterior peridiscal osteophytes at the L2-L3 and L3-L4 levels.

6. Group I arachnoiditis over the L2 to L4 levels.
7. Slight anterior wedging of the D11, D12 and L1 vertebral bodies without change in signal intensity, may be the sequelae of previous trauma.











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