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sb/hs/nl/nl
A Date : 00.00.00

Name of the Patient : Abc Xyz Dlmn / F / 72 yrs.
Referred by : Dr. Abc Xyznghal.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain to BLE (left more than right) with paresthesias in the LLE.
Alleged H/O fall 2 months back with retention of urine for 3 days.
C/O gait imbalance and loss of sensation of the LLE since then.

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 slight scoliosis of the lumbar spine with convexity to the left.

There is loss of water content of the lumbar intervertebral discs.

There is a left postero-lateral and left far disc herniation at the L4-L5 level with left neural foraminal narrowing. There is also slight facetal and ligamentum flavum hypertrophy at the L4-L5 level on the left, with impingement of the foraminal segment of the exiting left L4 nerve root.

A posteriorly herniated disc with peridiscal osteophytes is noted at the L3-L4 level, with slight bilateral neural foraminal narrowing. Facetal hypertrophy is seen at this level.
..2/.





- 2 - Scan-00005A


Far lateral (extraforaminal) disc bulges are seen bilaterally at the L2-L3 and L3-L4 levels and on the right side at the L4-L5 level.

A small posterior disc bulge with peridiscal osteophytes is noted at the L2-L3 level. The facet joints at this level appear slightly hypertrophied with facet joint effusion on the right.

Facetal hypertrophy is noted at the D9-D10 and D10-D11 levels bilaterally and on the left side at the D11-D12 level.

The lumbar vertebral bodies reveal normal signal intensity. 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.

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

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

IMPRESSION :

1. A left postero-lateral and left far disc herniation at the L4-L5 level with slight facetal and ligamentum flavum hypertrophy at the L4-L5 level on the left, with impingement of the foraminal segment of the exiting left L4 nerve root.
..3/.









- 3 - Scan-00005A



2. A posteriorly herniated disc with peridiscal osteophytes and facetal hypertrophy at the L3-L4 level.

3. A small posterior disc bulge with peridiscal osteophytes at the L2-L3 level with slight facetal hypertrophy and facet joint effusion on the right at this level.

4. Facetal hypertrophy at the D9-D10 and D10-D11 levels bilaterally and on the left side at the D11-D12 level.




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