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Date : 00.00.00

Name of the Patient : Abc Xyz Maklmn / M / 51 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE (right more than left) with paresthesias since 3-4 years.

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 slight retroplacement of the L5 over the S1 vertebra.

There is a posterior and right postero-lateral disc herniation at the L5-S1 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L5-S1 facet joint on the left side shows hypertrophic degenerative change. There is indentation upon the right S1 nerve root.

Posterior and a left postero-lateral disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and left neural foraminal narrowing. A part of the disc fragment is seen to migrate inferiorly in the right lateral recess posterior to the L5 vertebra with impingement of the right L5 nerve root. There is indentation upon the foraminal and extraforaminal portion of the left L4 nerve root. The L4-L5 facet joint on the left side shows hypertrophic degenerative change with left lateral recess stenosis. Ligamentum flavum hypertrophy is seen on the left side at the L5 level with lumbar canal stenosis.
..2/.




- 2 - scan-00006


Anterior disc herniations with large peridiscal osteophytes are seen in the lower dorsal and lumbar region. Schmorls node is seen in the inferior aspect of the D12 vertebral body. The lumbar intervertebral discs except for the L1-L2 and L3-L4 discs show loss of water content.

The rest of the lumbar facet joints show mild degenerative change.

The lumbar vertebral bodies show diffuse fatty changes.

The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1-L2 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 :

17.0 mm at L1-L2
16.0 mm at L2-L3
14.0 mm at L3-L4
14.0 mm at L4-L5
12.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. Slight retroplacement of the L5 over the S1 vertebra with a posterior and right postero-lateral disc herniation at the L5-S1 level with indentation upon the right S1 nerve root and hypertrophic facetal arthropathy on the left side at this level.
..3/.









- 3 - scan-00006


2. Posterior and a left postero-lateral disc herniation at the L4-L5 level with indentation upon the foraminal and extraforaminal portion of the left L4 nerve root with a part of the disc seen to lie posterior to the L5 vertebral body with impingement of the right L5 nerve root with canal stenosis. There is also hypertrophic facetal arthropathy on the left side with left lateral recess stenosis at this level.




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