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ke/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz K. Blmn / F / 40 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O low back pain radiating to the RLE since December 0000.
H/O microlumbar discectomy done in January 0000 for similar complaints.

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 L4 over the L5 vertebra.

There are post-operative changes in the posterior soft tissues at the L4 and L5 levels with partial laminectomy at the L4 level on the right side.

There is a postero-central disc herniation at the L4-L5 level with anterior indentation of the thecal sac and mild right neural foraminal narrowing. Inferior migration of the disc is noted which is seen to lie in the right lateral recess of L5 vertebra with impingement of the right L5 nerve root. The L4-L5 facet joints show mild degenerative change.

A small right postero-lateral disc herniation is seen at the L3-L4 level with mild right neural foraminal narrowing. This disc is reduced in height. The L3-L4 and L4-L5 intervertebral discs show loss of water content.


Type II degenerative changes are noted in the L4 and L5 vertebrae adjacent to the L4-L5 intervertebral disc. Type II/III degenerative changes are seen in the L3 and L4 vertebrae adjacent to the L3-L4 intervertebral disc.

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 D12-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 :

16.0 mm at L1-L2
15.0 mm at L2-L3
13.0 mm at L3-L4
9.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

1. Post-operative status.

2. A postero-central disc herniation at the L4-L5 level with inferior migration of the disc lying in the right lateral recess of L5 vertebra with impingement of the right L5 nerve root.

3. A small right postero-lateral disc herniation at the L3-L4 level.

Previous investigations were not available for comparison.
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