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sb/bv/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz Plmn / F / 65 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias (right more than left) since 1 1/2 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 loss of water content of the lumbar intervertebral discs with change in the normal lordotic curve.

There is probable sacralization of the L5 vertebra (Please compare with plain radiographs).

There is retroplacement of the L5 over the S1 vertebra.

There is a fairly large, posteriorly herniated disc at the L5-S1 level with bilateral neural foraminal narrowing. Slight inferior migration of the disc fragment is noted, posterior to the S1 vertebral body, more to the right of the midline impinging the traversing right S1 nerve root.

A posteriorly herniated disc is noted at the L4-L5 level with bilateral neural foraminal narrowing.

A posteriorly herniated disc is noted at the L3-L4 level with a small postero-central disc protrusion.


Small postero-central disc herniations are noted at the L1-L2 and L2-L3 levels.

Anterior peridiscal osteophytes are seen in the lower lumbar region.

The pedicles of the lumbar vertebrae appear congenitally short in their antero-posterior dimensions. Slight facetal hypertrophy is also noted in the lower lumbar region.

Schmorls nodes are identified in the L1, L2 and L3 vertebrae.

The lumbar vertebral bodies show spotty fatty marrow changes. The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the 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 :

14.0 mm at L1-L2
13.0 mm at L2-L3
15.0 mm at L3-L4
11.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

1. Probable sacralization of the L5 vertebra (Please compare with plain films).

2. Retroplacement of the L5 over the S1 vertebra.

3. A fairly large, posteriorly herniated disc at the L5-S1 level with bilateral neural foraminal narrowing with slight inferior migration of the disc fragment, more to the right of the midline impinging the traversing right S1 nerve root.
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4. A posteriorly herniated disc at the L4-L5 level with bilateral neural foraminal narrowing.

5. A posteriorly herniated disc at the L3-L4 level with a small postero-central disc protrusion.

6. Small postero-central disc herniations at the L1-L2 and L2-L3 levels.

7. Congenitally short pedicles of the lumbar vertebrae in their antero-posterior dimensions.

8. Slight facetal hypertrophy in the lower lumbar region.

9. Canal stenosis at the L4-L5 and L5-S1 levels.
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