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Name of the Patient : Abc Xyz lmn / M / 43 yrs.
Referred by : Dr. Abc Xyzmani.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the LLE with numbness.
H/O L4-L5 laminectomy and discectomy done on 00.00.00.

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 sacralization of the L5 vertebra and the L1 vertebral body is as marked on the film. There is mild retroplacement of the L4 over the L5 vertebra.

There is evidence of partial laminectomy at L3 and L4 vertebral levels with post-operative changes in the soft tissues in the posterior lumbar region at these levels.

There is loss of water content of the L3-L4 and L4-L5 intervertebral discs.

There is a posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level indenting the dural theca anteriorly.

A small, right postero-lateral protruded disc with peridiscal osteophytes is noted at the L3-L4 level with slight right neural foraminal narrowing.

Type II degenerative marrow changes are noted adjacent to the L4-L5 disc.
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There is clumping of the nerve roots at the L3-L4 level suggestive of arachnoiditis.

The rest of the 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 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 :

20.0 mm at L1-L2
19.0 mm at L2-L3
13.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebra.

2. Post-operative status.

3. A posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level.

4. A small, right postero-lateral protruded disc with peridiscal osteophytes at the L3-L4 level.

5. Clumping of the nerve roots at the L3-L4 level.

No previous investigations were available for comparison.

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