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sb/ke/nl/nl
Date : 00.00.00

Name of the Patient : Abc XyzAkolalmn / M / 70 yrs.
Referred by : Dr. Abc Xyzrani.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE and paresthesias.

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 L1-L2, L2-L3 and L5-S1 intervertebral discs.

There is slight central and anterior wedging of the L3 and L4 vertebral bodies. The L3-L4 disc space appears slightly widened. The L3-L4 and L4-L5 intervertebral discs appear hyperintense on the T2 Weighted images.

The L3 and L4 vertebral bodies adjacent to the L3-L4 disc appears hypointense on all the pulse sequences.

Generalized bulge of the L3-L4 and L4-L5 intervertebral discs is noted, with thecal sac compression and bilateral neural foraminal narrowing. Postero-lateral and far lateral disc herniations are also noted at these levels with indentation on the foraminal and extraforaminal segments of the L3 and L4 nerve roots.
Scan-00002



A left far lateral disc bulge with peridiscal osteophyte is noted at the L2-L3 level minimally indenting the extraforaminal segment of the left L2 nerve root.

Hypertrophic facetal arthropathy is noted at the L5-S1 level on the right and at the L4-L5 level bilaterally. Facetal hypertrophy is noted at the L5-S1 level on the left and at the L1-L2, L2-L3 and L3-L4 levels bilaterally.

The intrathecal nerve roots over the L4 and L5 vertebral levels appear clumped, centrally. There is significant canal stenosis at the L3-L4 and L4-L5 levels.

A scar is noted in the posterior soft tissues in the lumbar region at the L3 and L4 vertebral levels.

Anterior disc herniations with peridiscal osteophytes is noted in the lumbar region.

The rest of 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-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 :

17.0 mm at L1-L2
16.0 mm at L2-L3
9.0 mm at L3-L4
8.0 mm at L4-L5
13.0 mm at L5-S1.
..3/.









- 3 - Scan-00002



IMPRESSION :

1. Slight central and anterior wedging of the L3 and L4 vertebral bodies with altered signal adjacent to the L3-L4 disc and altered signal of the L3-L4 and L4-L5 intervertebral discs may be the sequelae of previous osteitis and discitis.

2. Generalized bulge of the L3-L4 and L4-L5 intervertebral discs with postero-lateral and far lateral disc herniations at these levels with indentation on the foraminal and extraforaminal segments of the L3 and L4 nerve roots.

3. A left far lateral disc bulge with peridiscal osteophyte at the L2-L3 level minimally indenting the extraforaminal segment of the left L2 nerve root.

4. Hypertrophic facetal arthropathy at the L5-S1 level on the right and at the L4-L5 level bilaterally.

5. Facetal hypertrophy at the L5-S1 level on the left and at the L1-L2, L2-L3 and L3-L4 levels bilaterally.

6. Significant canal stenosis at the L3-L4 and L4-L5 levels.

As compared to the previous MRI (study no:0000) dated 00.00.0000, the L3 and L4 vertebral bodies now appear wedged with altered signal of the L3-L4 and L4-L5 intervertebral discs. There is increase in the degree of canal stenosis of the L3-L4 and L4-L5 levels.



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