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ke/sb/nl/rg.
Date : 00.00.00

Name of the Patient : Abc XyzSoparilmn / M / 65 yrs.
Referred by : Dr. Abc Xyztchha.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the LLE with paresthesias in BLE.

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 retroplacement of the L4 over the L5 vertebral body. A large pseudoposterior disc herniation is noted at the L4-L5 level with anterior indentation of the thecal sac, bilateral neural foraminal narrowing and indentation upon the foraminal portion of the L4 nerve roots. The L4-L5 facet joints show degenerative changes with ligamentum flavum hypertrophy and resultant canal stenosis.

A posterior and left far lateral disc herniation is seen at the L5-S1 level with bilateral neural foraminal narrowing and indentation on the foraminal and extraforaminal portion of the left L5 nerve root.

Small posterior disc bulge is noted at the L3-L4 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. Small posterior disc herniations with peridiscal osteophytes are seen at the D12-L1 and L1-L2 levels. Anterior disc herniations with peridiscal osteophytes are noted in the lumbar region.


The lumbar intervertebral discs except for the L2-L3 disc show loss of water content.

Focal fatty changes are noted in lower dorsal and lumbar vertebral bodies. The D12 and L1 vertebral bodies are wedged anteriorly.

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

The lumbar facet joints show degenerative changes.

The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12 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 :

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

IMPRESSION :

1. Retroplacement of the L4 over the L5 vertebral body.

2. A large pseudoposterior disc herniation at the L4-L5 level with indentation upon the foraminal portion of the L4 nerve roots, facetal arthropathy, ligamentum flavum hypertrophy and resultant canal stenosis.
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3. A posterior and left far lateral disc herniation at the L5-S1 level with bilateral neural foraminal narrowing and indenting the foraminal and extraforaminal portion of the left L5 nerve root.

4. Small posterior disc bulge at the L3-L4 level.

5. Small posterior disc herniations with peridiscal osteophytes at the D12-L1 and L1-L2 levels.

6. Facetal arthropathy in the lumbar region.

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


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