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sb/hs/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyza Salmn / F / 41 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O pain in the LLE with paresthesias.
C/O situs inversus.
Past H/O cervical lymphadenopathy. Has received AKT.

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 :

The L5 vertebra appears to be as marked on the film.

There is loss of water content of the D11-D12, D12-L1, L1-L2, L3-L4 and L4-L5 intervertebral discs.

Minimal forward translation of the L4 vertebra over the L5 vertebra is noted, without obvious spondylolysis. Also seen is mild retroplacement of the L3 vertebra over the L4 vertebra.

There is a posteriorly herniated disc at the L4-L5 level with bilateral neural foraminal narrowing. There is ligamentum flavum hypertrophy with a resultant canal stenosis at that level.

Bilateral far lateral (extraforaminal) disc herniations are seen at the L4-L5 level and on the right side at the L3-L4 level.


The L4-L5 and L5-S1 facet joints show severe hypertrophic degenerative changes.

A small posterior disc herniation with a peridiscal osteophyte is noted at the L3-L4 level with bilateral neural foraminal narrowing. Slight facetal hypertrophy is also noted at this level.

A postero-central disc protrusion is noted at the L5-S1 level.

Small postero-central disc herniations with peridiscal osteophytes are noted at the D12-L1 and L1-L2 levels.

The lumbar vertebral bodies are more hypointense than normal on the T1 Weighted images (? preponderance of hematopoeitic marrow). The remaining intervertebral discs reveal normal signal intensity. 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 :

15.0 mm at L1-L2
19.0 mm at L2-L3
18.0 mm at L3-L4
11.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

1. Minimal forward translation of the L4 over the L5 vertebra and mild retroplacement of the L3 vertebra over the L4 vertebra.
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2. A posteriorly herniated disc at the L4-L5 level with bilateral neural foraminal narrowing, severe hypertrophic facetal arthropathy and ligamentum flavum hypertrophy with resultant canal stenosis at that level.

3. Severe hypertrophic facetal arthropathy at the L5-S1 level.

4. A small posterior disc herniation with a peridiscal osteophyte at the L3-L4 level with slight facetal hypertrophy at this level.

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

6. Bilateral far lateral (extraforaminal) disc herniations at the L4-L5 level and on the right side at the L3-L4 level.

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