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hs/ke/rg/nl.
Date : 00.00.00

Name of the Patient : Abc Xyzheb Nlmn / M / 40 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with radiation of pain to BLE with paresthesias.

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 :

A small posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina (right more than left) with impingement of the foraminal portion of the exiting right L4 nerve root at the L4-L5 level. A small right far lateral (extraforaminal) disc herniation is seen to indent the extraforaminal portion of the exiting right L4 nerve root at this level.

Mild posterior disc bulges are noted at the L3-L4 and L5-S1 levels. Posterior peridiscal osteophytes are seen at the D11-D12 level.

There is anterior wedging of the D12 vertebral body. A Schmorls node is noted at its superior aspect with adjacent Type II degenerative changes.

The lumbar facet joints show mild degenerative changes. The pedicles of the lower lumbar vertebrae appear congenitally short in their antero-posterior dimensions.

The D10-D11, D11-D12 and L4-L5 intervertebral discs show loss of water content.
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The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 :

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

IMPRESSION :

The MRI features are suggestive of :

1. A small posterior disc herniation with impingement of the foraminal portion of the exiting right L4 nerve root at the L4-L5 level.

2. A small right far lateral (extraforaminal) disc herniation indenting the extraforaminal portion of the exiting right L4 nerve root at the L4-L5 level.

3. Mild facetal arthropathy in the lumbar region.

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