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sb/ke/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzulmn / M / 76 yrs.
Referred by : Dr. Abc Xyzlkaka.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE since 2 months.
C/O weakness of the RLE since 1 month.
H/O Pulmonary kochs since October 0000. On AKT since then.

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 lumbar intervertebral discs.

There is slight forward translation of the L5 over the S1 vertebra with probable spondylolysis at L5, bilaterally. A resultant pseudoposterior disc bulge is noted at this level.

Posteriorly bulging discs are noted at the L2-L3, L3-L4 and L4-L5 levels with slight bilateral neural foraminal narrowing with indentation on the extraforaminal segment of the left L3 nerve root at the L3-L4 level.

Anterior disc herniations with anterior peridiscal osteophytes are noted in the upper lumbar region.

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 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
13.0 mm at L3-L4
14.0 mm at L4-L5
15.0 mm at L5-S1.

Screening, T2 Weighted sagittal and axial images of the dorsal spine reveal small postero-central protruded disc with peridiscal osteophytes at the D9-D10 and D8-D9 levels. The visualized dorsal spinal cord shows normal signal.

Screening, T2 Weighted sagittal images and T1 Weighted and Fast Scan (T2 *) axial images of the cervical region reveal loss of water content of the cervical intervertebral discs. A fairly large, posteriorly extruded disc is noted at the C5-C6 level with superior migration of the disc fragment and cord compression.

Small postero-central disc herniations with peridiscal osteophytes are noted at the C2-C3, C3-C4, C4-C5 and C6-C7 levels. Ligamentum flavum hypertrophy is noted at the C5 vertebral level. There is slight forward translation of the C4 over the C5 vertebral body.

IMPRESSION :

1. Slight forward translation of the L5 over the S1 vertebra with probable spondylolysis at L5, bilaterally with a resultant pseudoposterior disc bulge at this level.
..3/.









- 3 - Scan-00007




2. Posteriorly bulging discs at the L2-L3, L3-L4 and L4-L5 levels with slight bilateral neural foraminal narrowing and indentation on the extraforaminal segment of the left L3 nerve root at the L3-L4 level.

3. Small postero-central protruded discs with peridiscal osteophytes at the D9-D10 and D8-D9 levels.

4. A fairly large, posteriorly extruded disc at the C5-C6 level with superior migration of the disc fragment and cord compression.

5. Small postero-central disc herniations with peridiscal osteophytes at the C2-C3, C3-C4, C4-C5 and C6-C7 levels.


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