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hs/ke/rg.
Date : 00.00.00

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

CLINICAL PROFILE :

C/O backache with pain radiating to BLE with numbness and loss of sensation in the LLE 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 loss of water content of the L3-L4, L4-L5 and L5-S1 intervertebral discs.

There is mild retroplacement of the L5 over the S1 and the L4 over the L5 vertebrae.

There is a large posterior disc extrusion with peridiscal osteophytes at the L5-S1 level with inferior migration of the disc portion with resultant indentation upon both the traversing S1 nerve roots. Also seen is mild bilateral neural foraminal narrowing with indentation upon the exiting L5 nerve roots at this level.

A postero-central disc herniation with peridiscal osteophytes is seen to indent the thecal sac at the L3-L4 level.

A posterior disc herniation with peridiscal osteophytes is seen to indent the thecal sac with slight bilateral neural foraminal narrowing at the L4-L5 level.
..2/.






Bilateral far lateral (extraforaminal) disc herniations are noted at the L4-L5 and L5-S1 levels.

Facetal hypertrophy is seen at the L4-L5 and L5-S1 levels. Also seen is mild ligamentum flavum hypertrophy at these levels.

Type I degenerative changes (hypointense on the T1 Weighted images and hyperintense on the T2 Weighted images) are noted in the L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral disc.

An anterior disc herniation is seen at the L5-S1 level.

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 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 :

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

The dorsal spine was screened with 4 mm thick T2 Weighted sagittal images and is unremarkable.

IMPRESSION :

The MRI features are suggestive of :

1. A posterior disc extrusion with peridiscal osteophytes at the L5-S1 level with inferior migration of the disc portion and indentation upon both the traversing S1 nerve roots. ..3/.


- 3 - Scan-00008

3. A postero-central disc herniation with peridiscal osteophytes at the L3-L4 level.

4. A posterior disc herniation with peridiscal osteophytes at the L4-L5 level.

4. Facetal hypertrophy at the L4-L5 and L5-S1 levels with mild ligamentum flavum hypertrophy at these levels.

5. Canal stenosis at L5-S1 level and a tight canal at the L4-L5 level.

6. Type I degenerative changes in the L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral disc (less likely to be osteitis).

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