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ke/sb/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzakant P. Jogllmn / M / 43 yrs.
Referred by : Dr. Abc Xyzzare.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE with paresthesias.

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 partial sacralization of the L5 vertebra on the left side.

A posterior disc herniation with peridiscal osteophytes is seen at the L4-L5 level with anterior indentation of the thecal sac and right neural foraminal narrowing. A large disc fragment is seen to migrate inferiorly in the right lateral recess of the L5 vertebral body with impingement of the traversing right L5 nerve root. There is resultant canal stenosis at the L5 level. This disc shows loss of water content.

The L1-L2 and L2-L3 intervertebral discs show slight loss of water content.

The visualized dorso-lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The visualized lower dorsal spinal cord reveals normal signal intensity.
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The conus medullaris terminates at the L1 level and 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 :

14.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
10.0 mm at L4-L5
7.0 mm at L5-S1.

The dorsal and cervico-dorsal spine was screened with 4 mm thick T2 Weighted sagittal images and reveal small posterior disc bulges at the C4-C5, C5-C6 and D11-D12 levels.

IMPRESSION :

1. Partial sacralization of the L5 vertebra on the left side.

2. A posterior disc herniation with peridiscal osteophytes at the L4-L5 level with a large disc fragment seen to migrate inferiorly in the right lateral recess of the L5 vertebral body with impingement of the traversing right L5 nerve root and resultant canal stenosis at the L5 level.


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