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ke/hs/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyza Almn / F / 66 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 RLE since 6 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 slight forward translation of the L4 vertebra over the L5 vertbera. Also seen is slight retroplacement of the L1 vertebra over the L2 vertebra.

A pseudoposterior disc herniation is seen at the L4-L5 level with anterior indentation of thecal sac. The L4-L5 facet joints show hypertrophic degenerative changes with a resultant tight canal.

A small posterior and bilateral far lateral disc herniations are noted at L5-S1 level with mild indentation upon the extraforaminal portion of the exiting L5 nerve roots.

A posterior disc bulge with small peridiscal osteophytes is seen at the L1-L2 level. An anterior disc herniation is also noted at this level.

Small posterior disc bulges are noted at the L2-L3 and L3-L4 levels. The lumbar intervertebral discs show loss of water content.

The L5-S1 facet joints show degenerative changes.
..2/.






Type II degenerative changes are seen within the L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral disc.

Focal fatty changes are seen in upper lumbar vertebral bodies.

The rest of the facet joints and 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 :

16.0 mm at L1-L2
15.0 mm at L2-L3
14.0 mm at L3-L4
11.0 mm at L4-L5
9.0 mm at L5-S1.

IMPRESSION :

1. Slight forward translation of the L4 vertebra over the L5 vertebra and mild retroplacement of the L1 vertebra over the L2 vertebra.

2. A pseudoposterior disc herniation at the L4-L5 level with hypertrophic facetal arthropathy and a resultant tight canal.

3. A small posterior and bilateral far lateral disc herniations at L5-S1 level.





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