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sb/ke/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzanta V. Mlmn / F / 68 yrs.
Referred by : Dr. Abc XyzPatel.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE with paresthesias since 1 month.

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 reduction in height of the L5-S1 intervertebral disc and loss of water content of the lumbar intervertebral discs. The L5-S1 intervertebral disc shows evidence of calcium/vacuum phenomena.

A posteriorly bulging disc with peridiscal osteophytes is noted at the L5-S1 level with bilateral neural foraminal narrowing. An anterior disc herniation with peridiscal osteophytes is also seen at this level.

A fairly large postero-central disc herniation is noted at the L4-L5 level with thecal sac compression. There is facetal and ligamentum flavum hypertrophy with resultant canal stenosis at this level.

A left far lateral disc herniation is noted at the L3-L4 level with slight left neural foraminal narrowing. Slight facetal hypertrophy is also noted at this level.

Small postero-central protruded discs are noted at the L1-L2 and L2-L3 levels with slight facetal hypertrophy at L2-L3 level.
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Type II degenerative change is seen in the L5 and S1 vertebrae adjacent to the L5-S1 intervertebral disc.

The rest of the lumbar vertebral bodies 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 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
18.0 mm at L2-L3
17.0 mm at L3-L4
13.0 mm at L4-L5
13.0 mm at L5-S1.

IMPRESSION :

1. A fairly large postero-central disc herniation at the L4-L5 level with facetal and ligamentum flavum hypertrophy and resultant canal stenosis at this level.

2. A posteriorly bulging disc with peridiscal osteophytes at the L5-S1 level.

3. A left far lateral disc herniation at the L3-L4 level with slight facetal hypertrophy at this level.

4. Small postero-central protruded discs at the L1-L2 and L2-L3 levels with slight facetal hypertrophy at L2-L3 level.
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