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ke/hs/nl.rg.
Date : 00.00.00

Name of the Patient : Abc Xyzra P. Upalmn / M / 37 yrs.
Referred by : Dr. Abc Xyzasde.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

Alleged H/O fall with injury to the right hip region 2 years back. Recovered with conservative treatment.
Now C/O low back pain, radiating to the LLE with limp and paresthesias in the right foot 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 a large postero-central disc extrusion with peridiscal osteophytes at the L5-S1 level with anterior compression of the thecal sac and canal stenosis. Inferior migration of the disc is seen with impingement of the traversing left S1 nerve root. The L5-S1 facet joint on the left side shows degenerative changes. This disc shows loss of water content.

Left postero-lateral and left far lateral disc herniations are seen at the L4-L5 level with indentation upon the extraforaminal portion of the exiting left L4 nerve root at the L4-L5 level. The L4-L5 facet joints show degenerative changes. This disc shows loss of water content. A postero-central disc bulge is seen at the L4-L5 level.

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.
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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 :

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

IMPRESSION :

1. A large postero-central disc extrusion with peridiscal osteophytes at the L5-S1 level with canal stenosis. Inferior migration of the disc is seen with impingement of the travesing left S1 nerve root.

2. Left postero-lateral and left far lateral disc herniations at the L4-L5 level with indentation upon the extraforaminal portion of the exiting left L4 nerve root.

3. Facetal arthropathy bilaterally at the L4-L5 level and on the left side at the L5-S1 level.
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