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hs/sb/rg.
Date : 00.00.00

Name of the Patient : Abc Xyznalmn / M / 53 yrs.
Referred by : Dr. Abc Xyzdy.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache since 00.00.00.
H/O lifting heavy weight.

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 :

Posterior disc herniations with small peridiscal osteophytes are seen to indent the thecal sac and narrow both neural foramina at the L4-L5 and L5-S1 levels. The facet joints at these levels show severe hypertrophic degenerative changes. Ligamentum flavum hypertrophy is seen over the L4-L5 to the L5-S1 level.

A mild posterior disc bulge is seen at the L3-L4 level. The L3-L4 facet joints show hypertrophic degenerative changes.

Far lateral (extraforaminal) disc herniations are seen bilaterally at the L5-S1 level and on the left side at the L4-L5 level. Right far lateral (extraforaminal) disc bulges are seen at the L3-L4 and L4-L5 levels.

The L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content. Type II degenerative changes are seen within the L4, L5 and S1 vertebral bodies adjacent to the L4-L5 and L5-S1 intervertebral discs. There is irregularity of the cortical endplates at the L5-S1 level.
..2/.







There is facetal hypertrophy at the D11-D12 level.

Note is made of a renal cortical cyst on the right side.

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 :

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

IMPRESSION :

The MRI features are suggestive of :

1. Posterior disc herniations with small peridiscal osteophytes and severe hypertrophic facetal arthropathy
at the L4-L5 and L5-S1 levels.

2. A mild posterior disc bulge with hypertrophic facetal arthropathy at the L3-L4 level.

3. Far lateral (extraforaminal) disc herniations are seen bilaterally at the L5-S1 level and on the left side at the L4-L5 level.

4. Right far lateral (extraforaminal) disc bulges at the L3-L4 and L4-L5 levels.

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


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