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sb/ke/rg/nl
Date : 00.00.00

Name of the Patient : Abc XyzDhlmn / M / 58 yrs.
Referred by : Dr. Abc Xyztchha.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with swelling over BLE 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 loss of normal lumbar lordosis and loss of water content of the lumbar intervertebral discs.

There is a small, right postero-lateral (foraminal) disc herniation at the L5-S1 level.

There is a postero-central and right postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with right neural foraminal narrowing and indentation on the traversing right L5 nerve root. The exiting right L4 nerve root is also impinged in the right neural foramen at the L4-L5 level. Slight superior migration of the disc fragment is also noted.

A posterior and left postero-lateral disc herniation with peridiscal osteophytes is noted at the L3-L4 level, indenting the extraforaminal segment of the left L3 nerve root.


A small, postero-central protruded disc is noted at the L1-L2 level.

The facet joints at the L3-L4, L4-L5 and L5-S1 levels bilaterally and on the left at the L2-L3 level appear hypertrophied.

Anterior disc herniation with anterior peridiscal osteophytes is noted at the L4-L5 level.

Type II degenerative marrow changes are noted adjacent to the L3-L4 and L4-L5 discs.

The rest of the lumbar vertebral bodies 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 :

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

IMPRESSION :

1. A small, right postero-lateral (foraminal) disc herniation at the L5-S1 level.
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- 3 - Scan-00007


2. A postero-central and right postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with right neural foraminal narrowing and indentation on the traversing right L5 nerve root. The exiting right L4 nerve root is also impinged in the right neural foramen at the L4-L5 level.

3. A posterior and left postero-lateral disc herniation with peridiscal osteophytes at the L3-L4 level, indenting the extraforaminal segment of the left L3 nerve root.

4. A small, postero-central protruded disc at the L1-L2 level.

5. Facetal hypertrophy at the L3-L4, L4-L5 and L5-S1 levels bilaterally and on the left at the L2-L3 level.

6. Tight lumbar canal at the L3-L4 and L4-L5 levels.

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