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sb/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz Klmn / F / 30 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE since 00.00.00.

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 lumbar intervertebral discs except the L1-L2 disc.

There is sacralization of the L5 vertebra and the L1 vertebral body is as marked on the film. There is reduction in height of the L4-L5 intervertebral disc.

There is a fairly large, posteriorly extruded disc at the L4-L5 level with inferior migration of the disc fragment more to the right of the midline indenting the traversing right L5 nerve root (scans 104.5 & 104.6). The right L5 nerve root appears to be of larger calibre and is probably inflamed (scan 104.4).

Small postero-central disc herniations are noted at the L2-L3 and L3-L4 levels with right far lateral (extraforaminal) disc bulges at these levels.

Type II degenerative marrow changes are noted adjacent to the L4-L5 intervertebral disc.


Anterior disc herniations are seen at the L1-L2, L2-L3 and L4-L5 levels.

The rest of the lumbar vertebral bodies reveal normal signal intensity. The facet joints and 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 :

17.0 mm at L1-L2
12.0 mm at L2-L3
11.0 mm at L3-L4
9.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebra and the L1 vertebral body is as marked on the film.

2. A fairly large, posteriorly extruded disc at the L4-L5 level with inferior migration of the disc fragment more to the right of the midline indenting the traversing right L5 nerve root, which appears inflamed.

3. Small postero-central disc herniations at the L2-L3 and L3-L4 levels.

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