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hs/ke/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz Shlmn / F / 52 yrs.
Referred by : Dr. Abc Xyzauhan.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE (right more than left) 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 :

The L5 vertebra is as marked on the film.

Posterior disc herniations with peridiscal osteophytes are seen to narrow both neural foramina at the L4-L5 and L5-S1 levels with mild indentation upon the thecal sac at the L4-L5 level.

A right far lateral (extraforaminal) disc herniation is seen to indent the extraforaminal portion of the exiting right L5 nerve root at the L5-S1 level.

Posterior disc bulges with peridiscal osteophytes are seen to indent the thecal sac at the L1-L2, L2-L3 and L3-L4 levels. Bilateral far lateral (extraforaminal) disc bulges are noted at the L3-L4 and L4-L5 levels and on the right side at the L2-L3 level.

The L4-L5 and L5-S1 facet joints show hypertrophic degenerative changes. Facetal hypertrophy is seen at the L3-L4 level.

There is ligamentum flavum hypertrophy at the L4-L5 level.
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R> Schmorls nodes are seen in the dorso-lumbar region.

Type II degenerative changes are seen in the L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral disc.

The lumbar intervertebral discs show loss of water content.

The rest of the lumbar vertebral bodies 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 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 :

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

A cystic lesion is seen in the pelvis on the right side and further evaluation would be worthwhile.

IMPRESSION :

The MRI features are suggestive of :

1. Posterior disc herniations with peridiscal osteophytes and hypertrophic facetal arthropathy at the L4-L5 and L5-S1 levels.

2. A right far lateral (extraforaminal) disc herniation at the L5-S1 level.
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- 3 - Scan-00001


3. Posterior disc bulges with peridiscal osteophytes at the L1-L2, L2-L3 and L3-L4 levels.

4. Facetal hypertrophy at the L3-L4 level.

5. Ligamentum flavum hypertrophy at the L4-L5 level.



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