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sb/hs/rg/nl
Date : 00.00.00

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

CLINICAL PROFILE :

C/O radicular pain in BLE with paresthesias since 7-8 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 normal lumbar lordosis and loss of water content of the L2-L3, L4-L5 and L5-S1 intervertebral discs.

A posterior disc bulge and a right postero-lateral disc herniation is noted at the L5-S1 level with right neural foraminal narrowing and minimal indentation on the traversing right S1 nerve root.

A posteriorly herniated disc with peridiscal osteophytes is noted at the L4-L5 level with thecal sac compression, bilateral neural foraminal narrowing and indentation of the traversing left L5 nerve root.

Left and right postero-lateral disc bulges are noted at the L3-L4 level with bilateral neural foraminal narrowing.

A postero-central and left postero-lateral disc herniation is noted at the L2-L3 level with left neural foraminal narrowing.


Far lateral (extraforaminal) disc herniations are seen bilaterally over the L2-L3 to the L5-S1 levels.

The pedicles of the lumbar vertebrae appear congenitally short in their antero-posterior dimensions.

Facetal hypertrophy is noted in the lumbar region and ligamentum flavum hypertrophy is noted at the L4-L5, L5 and L5-S1 levels.

The lumbar vertebral bodies and the remaining intervertebral discs 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 :

14.0 mm at L1-L2
12.0 mm at L2-L3
12.0 mm at L3-L4
9.0 mm at L4-L5
7.0 mm at L5-S1.

IMPRESSION :

1. A posterior disc bulge and a right postero-lateral disc herniation at the L5-S1 level with minimal indentation on the traversing right S1 nerve root.

2. A posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level indenting the traversing left L5 nerve root.
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3. Left and right postero-lateral disc bulges at the L3-L4 level.

4. A postero-central and left postero-lateral disc herniation at the L2-L3 level.

5. Congenitally short pedicles of the lumbar vertebrae in their antero-posterior dimensions.

6. Facetal hypertrophy in the lumbar region and ligamentum flavum hypertrophy at the L4-L5, L5 and L5-S1 levels.

7. Lower lumbar canal stenosis, maximum at the L4-L5 level.





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