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ke/bv/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzli Salodalmn / M / 63 yrs.
Referred by : Dr. Abc Xyzagwati.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE for 3 days 3 months back.
C/O right foot drop since 3 months.

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 sacralization of the L5 vertebral body and the L4 vertebra is as marked on the film.

There is a diffuse posterior disc herniation with bilateral postero-lateral disc herniations at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. Indentation on the foraminal portion of the L4 nerve roots is seen. There is ligamentum flavum hypertrophy with facetal hypertrophy at this level with resultant tight canal.

The right L5 nerve root is of larger calibre as compared to the left and there is a suggestion of the right L5 nerve root being inflamed.

A posterior and bilateral far lateral disc herniation is seen at the L3-L4 level with anterior indentation of the thecal sac and the extraforaminal portion of the L3 nerve roots. The L3-L4 facet joint on the right shows mild degenerative change.


A diffuse posterior disc herniation is seen at the L2-L3 level with anterior indentation of the thecal sac. Right and left postero-lateral disc herniations are noted at this level with bilateral neural foraminal narrowing. Slight facetal arthropathy and ligamentum flavum hypertrophy is seen with central and lateral canal stenosis.

A small posterior disc bulge with small peridiscal osteophyte to the right of the midline is seen at the D12-L1 level.

Large anterior disc herniations are noted at the L2-L3 and L4-L5 levels.

A left paracentral and left postero-lateral disc herniation is seen at the L1-L2 level and a right paracentral disc herniation is noted at the D12-L1 level.

Type I degenerative change is seen in the L4 and L5 vertebral bodies adjacent to the L4-L5 intervertebral disc. Type II degenerative changes are noted in the antero-superior aspect of the L1, L3 and L4 vertebral bodies and the antero-inferior aspect of the L2 vertebral body.

The pedicles of the lumbar vertebrae are congenitally short in their antero-posterior dimensions.

Hypo and hyperintense areas are seen within the L4-L5 intervertebral disc on all the pulse sequences suggesting calcification/vacuum phenomena. The lumbar intervertebral discs except for the L2-L3 disc shows loss of water content.

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 S1 level.
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- 3 - Scan-00005


The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

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

IMPRESSION :

1. Sacralization of the L5 vertebral body and the L4 vertebra is as marked on the film.

2. A diffuse posterior disc herniation with bilateral far lateral disc herniations at the L4-L5 level with indentation on the thecal sac and the foraminal portion of the L4 nerve roots.

3. A suggestion of the right L5 nerve root being inflamed.

4. A posterior and bilateral far lateral disc herniations at the L3-L4 level with indentation upon extraforaminal portion of the L3 nerve roots.

5. A diffuse posterior disc herniation with right and left postero-lateral disc herniations at the L2-L3 level with bilateral neural foraminal narrowing.

6. Facetal arthropathy, ligamentum flavum hypertrophy and canal stenosis at the L2-L3 and L4-L5 levels.

7. Congenitally short pedicles of the lumbar vertebrae in the antero-posterior dimensions.


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