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sb/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz Almn / F / 35 yrs.
Referred by : Dr. Abc Xyzagwati.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

H/O fall with injury to cervical spine 10 years back. Operated (details not available).
C/O loss of control over bladder since then. Now C/O backache since 2 months.
H/O kochs 10 years back. Received AKT.

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 scoliosis of the lumbar spine with convexity to the left.

There is loss of water content of the L2-L3, L3-L4 and L4-L5 intervertebral discs.

Very small postero-central protruded discs are noted at the L2-L3 and L5-S1 levels.

Small posterior peridiscal osteophytes are noted at the L3-L4 and L4-L5 levels.

Slight facetal hypertrophy is noted in the lumbar region.

Type II degenerative marrow changes are noted in the L4 vertebral body adjacent to the L3-L4 intervertebral disc.

..2/.







The rest of 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 L2 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 :

18.0 mm at L1-L2
18.0 mm at L2-L3
17.0 mm at L3-L4
16.0 mm at L4-L5
14.0 mm at L5-S1.

There is evidence of fatty replacement of the posterior paraspinal muscles in the lower lumbar and sacral regions and probably also of the left psoas muscle.

IMPRESSION :

1. Slight scoliosis of the lumbar spine with convexity to the left.

2. Very small postero-central protruded discs at the L2-L3 and L5-S1 levels.

3. Small posterior peridiscal osteophytes at the L3-L4 and L4-L5 levels.

4. Slight facetal hypertrophy in the lumbar region.

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