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sb/hs/rg.
Date : 00.00.00

Name of the Patient : Abc Xyze Misqlmn / F / 68 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE with tingling sensations.

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.

There is minimal forward translation of the L4 vertebra over the L5 vertebra without obvious spondylolysis (kindly correlate with plain radiographs). Also seen is retroplacement of the L5 vertebra over the S1 vertebra.

There is a fairly large, posterior disc herniation at the L4-L5 level with thecal sac compression and bilateral neural foraminal narrowing. There is hypertrophic facetal arthropathy and slight ligamentum flavum hypertrophy and resultant severe canal stenosis at this level.

There is a posteriorly herniated disc with peridiscal osteophytes at the L5-S1 level with bilateral neural foraminal narrowing. Inferior migration of the disc is noted. A probable sequestered disc fragment is noted in the right lateral recess of S1 indenting the traversing right S1 nerve root. Facetal and ligamentum flavum hypertrophy is noted at the L5-S1 level with resultant canal stenosis.
..2/.






Bilateral far lateral (extraforaminal) disc herniations are noted at the L4-L5 and L5-S1 levels.

A small right postero-lateral disc herniation is seen to narrow the right neural foramen at the L3-L4 level.

Small posterior disc bulges are noted at the L1-L2 and L3-L4 levels. Slight facetal hypertrophy is noted at the L3-L4 level.

A hemangioma with fat content (hyperintense on all the pulse sequences) is noted in the L2 vertebral body.

The rest of the lumbar vertebral bodies reveal normal signal intensity. 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
15.0 mm at L2-L3
13.0 mm at L3-L4
5.0 mm at L4-L5
9.0 mm at L5-S1.

IMPRESSION :

1. Minimal forward translation of the L4 over the L5 vertebra without obvious spondylolysis (kindly correlate with plain radiographs).

2. A fairly large, posterior disc herniation at the L4-L5 level with hypertrophic facetal arthropathy and slight ligamentum flavum hypertrophy at that level.
..3/.






- 3 - Scan-00001


3. A posteriorly herniated disc with peridiscal osteophytes at the L5-S1 level with inferior migration of the disc and a probable sequestered disc fragment in the right lateral recess of S1 indenting the traversing right S1 nerve root. Facetal and ligamentum flavum hypertrophy is noted at the L5-S1 level.

4. Lower lumbar canal stenosis, more so at the L4-L5 level.
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