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hs/sb/rg/nl

Name of the Patient : Abc XyzHabib lmn / M / 75 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 with paresthesias since 1 1/2 months.
H/O pulmonary Kochs 20 years ago. Received AKT.
H/O Ca bronchus. Operated 4 years ago.

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 appears to be sacralization of the L5 vertebra and the L1 vertebra is as marked on the film. Please correlate with plain radiographs.

There is mild retroplacement of the L4 vertebra over the L5 vertebra. The lumbar intervertebral discs show loss of water content.

There is a posterior disc extrusion indenting the thecal sac and narrowing both neural foramina at the L4-L5 level. A sequestered disc portion is seen within the right lateral recess of the L5 vertebra with impingement of the traversing right L5 nerve root.

A small left postero-lateral disc herniation is seen to narrow the left neural foramen at the L3-L4 level. Postero-central disc protrusions are seen at the D12-L1 and L1-L2 levels. There is a posterior disc bulge at the L2-L3 level.


The lumbar facet joints show mild degenerative changes. The pedicles of the lumbar vertebrae appear congenitally short in their antero-posterior dimensions.

The lumbar vertebral bodies show areas of fatty replacement of normal marrow.

Far lateral disc bulges are noted bilaterally at the L3-L4 and L4-L5 levels and on the right side at the L1-L2, L2-L3 and L3-L4 levels.

Mild ligamentum flavum hypertrophy is noted at the L5-S1 level.

The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12-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
14.0 mm at L2-L3
13.0 mm at L3-L4
15.0 mm at L4-L5
13.0 mm at L5-S1.

The cervical and dorsal spines were screened with 5 mm thick T1 Weighted sagittal images and show areas of fatty replacement of normal marrow. Soft tissue intensity lesions are seen in the left lung and upper lobe of the right lung and may require further evaluation.
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IMPRESSION :

1. Sacralization of the L5 vertebra. Please correlate with plain radiographs.

2. A posterior disc extrusion at the L4-L5 level with a sequesterd disc portion within the right lateral recess of the L5 vertebra impinging the traversing right L5 nerve root.

3. Mild facetal arthropathy in the lumbar region.

4. Congenitally short pedicles of the lumbar vertebrae in their antero-posterior dimensions.

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