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Name of the Patient : Abc XyzGoylmn / M / 65 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE since 2 1/2 months.

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 :

A postero-central disc protrusion is seen to indent the thecal sac at the L5-S1 level.

There is a posterior disc bulge at the L4-L5 level with anterior indentation of the thecal sac.

Anterior disc herniations with peridiscal osteophytes are noted in the lumbar region. The lumbar intervertebral discs show loss of water content. Mild facetal hypertrophy is seen at the L4-L5 and L5-S1 levels.

Bilateral far lateral (extraforaminal)_ disc bulges are noted over the L2-L3 to L5-S1 levels.

Focal fatty changes with hamangioma is noted within the L2 vertebral body. Focal fatty change is also noted in the L4 vertebral body.

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.
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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 :

16.0 mm at L1-L2
15.0 mm at L2-L3
16.0 mm at L3-L4
13.0 mm at L4-L5
15.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

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

2. A posterior disc bulge at the L4-L5 level.

3. Mild facetal hypertrophy at the L4-L5 and L5-S1 levels.


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