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Name of the Patient : Abc Xyz Tlmn / F / 55 yrs.
Referred by : Dr. Abc Xyztchha.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the LLE 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 :

The L1 vertebral body is as marked on the film. Please correlate with plain radiographs.

The S1 and S2 vertebral bodies appear to be fused, with non-visualization of the S1-S2 intervertebral disc.

There is slight forward translation of the L5 vertebra over the S1 vertebra, without obvious spondylolysis.

There is loss of water content of the lumbar intervertebral discs.

There is a pseudoposterior disc herniation at the L5-S1 level with bilateral neural foraminal narrowing, more so on the right side. Severe hypertrophic facetal arthropathy is noted at this level with resultant canal stenosis.

Small posterior disc herniations with peridiscal osteophytes are noted at the L2-L3 and L4-L5 levels, with bilateral neural foraminal narrowing at the L4-L5 level.


Hypertrophic facetal arthropathy is noted at the L3-L4 and L4-L5 levels bilaterally.

The L5, S1 and S2 vertebral bodies show spotty fatty marrow changes.

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 L2-L3 level and the thecal sac terminates at the S2-S3 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
14.0 mm at L2-L3
12.0 mm at L3-L4
13.0 mm at L4-L5
12.0 mm at L5-S1.

IMPRESSION :

1. Fusion of the S1 and S2 vertebral bodies, with non-visualization of the S1-S2 intervertebral disc may be the sequelae of a previous infection/trauma.

2. Slight forward translation of the L5 vertebra over the S1 vertebra, without obvious spondylolysis.

3. A pseudoposterior disc herniation at the L5-S1 level with bilateral neural foraminal narrowing, more so on the right side. Severe hypertrophic facetal arthropathy is noted at this level with resultant canal stenosis.
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4. Small posterior disc herniations with peridiscal osteophytes at the L2-L3 and L4-L5 levels.

5. Hypertrophic facetal arthropathy at the L3-L4 and L4-L5 levels, bilaterally.

No previous X-rays/investigations were available for comparison.


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