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hs/ke/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzang Shilmn / M / 48 yrs.
Referred by : Dr. Abc Xyzchale.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

H/O backache with pain radiating to the LLE since 2-3 months.
C/O acute retention of urine since 15 days and weakness of the LLE.

EXAMINATION :

M.R.I of the lumbo-sacral spine was performed using the following parameters :

4 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. Please correlate with plain radiographs.

The lumbar intervertebral discs show loss of water content. Type II degenerative changes are seen within the L4, L5 and S1 vertebral bodies adjacent to the intervertebral discs.

A large posterior disc extrusion is seen to compress upon the thecal sac and narrow both neural foramina with impingement of the exiting left L5 nerve root at the L5-S1 level. A disc portion is seen within the anterior epidural space at the S1 vertebral level with resultant impingement of both the traversing S1 nerve roots.

A posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level.

A postero-central disc herniation with peridiscal osteophytes is seen to indent the thecal sac at the L1-L2 level.

Bilateral far lateral (extraforaminal) disc bulges are seen at the L1-L2, L4-L5 and L5-S1 levels.

The L4-L5 and L5-S1 facet joints show hypertrophic degenerative changes. The L1-L2, L2-L3 and L3-L4 facet joints show degenerative changes.

A posterior disc bulge is noted at the L3-L4 level. Small posterior peridiscal osteophytes are seen at the L4-L5 and L5-S1 levels.

The rest of the lumbar vertebral bodies reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12 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
14.0 mm at L2-L3
11.0 mm at L3-L4
10.0 mm at L4-L5
4.0 mm at L5-S1.

The dorsal spine was screened with 5 mm thick T2 Weighted sagittal images and which does not reveal any significant feature of note.

IMPRESSION :

The MRI features are suggestive of :

1. A large posterior disc extrusion at the L5-S1 level with severe canal stenosis and a disc portion seen within the anterior epidural space at the S1 vertebral level impinging both the traversing S1 nerve roots.
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2. A posterior disc herniation at the L4-L5 level with a tight canal.

3. A postero-central disc herniation with peridiscal osteophytes at the L1-L2 level.

4. Hypertrophic facetal arthropathy at the L4-L5 and L5-S1 levels and facetal arthropathy at the L1-L2, L2-L3 and L3-L4 levels.

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