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Name of the Patient : Abc Xyzain Pardalmn / M / 55 yrs
Referred by : Dr. Abc Xyzapadia.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O pain in 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 :

The L5 vertebral body is as marked on the film. There is mild retroplacement of the L5 vertebra over the S1 vertebra.

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

There is a posteriorly herniated disc with peridiscal osteophytes at the L5-S1 level with thecal sac compression and bilateral neural foraminal narrowing. A left far lateral disc herniation is also noted at this level with indentation upon the exiting left L5 nerve root. There is also facetal and ligamentum flavum hypertrophy with canal stenosis at this level.

A postero-central protruded disc is noted at the L4-L5 level. A right far lateral disc herniation is also noted at this level with indentation upon the extraforaminal segment of the exiting right L4 nerve root. Facetal and ligamentum flavum hypertrophy is also noted.



A small posterior disc bulge is noted at the L3-L4 level. Also seen is a left far lateral disc herniation at this level.

A small postero-central disc protrusion is seen at the D12-L1 level.

Far lateral disc bulges are seen on the right at the L3-L4 and L5-S1 levels and on the left at the L4-L5 level.

Type II degenerative marrow changes are noted adjacent to the L3-L4 and L4-L5 intervertebral discs. The L1 vertebral body is wedged slightly anteriorly with herniation of the D12-L1 disc into the body of L1. No signal change is however noted.

The rest of the lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1-L2 level and the thecal sac terminates at the 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
12.0 mm at L2-L3
13.0 mm at L3-L4
10.0 mm at L4-L5
7.0 mm at L5-S1.

Screening, T1 Weighted coronal images of the sacro-iliac joints and the hip joints do not reveal any significant feature of note.
..3/.








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IMPRESSION :

1. A posteriorly herniated disc with peridiscal osteophytes and a left far lateral disc herniation at the L5-S1 level. There is also facetal and ligamentum flavum hypertrophy with canal stenosis at this level.

2. A postero-central protruded disc at the L4-L5 level with a right far lateral disc herniation indenting the extraforaminal segment of the exiting right L4 nerve root. Facetal and ligamentum flavum hypertrophy is also noted.

3. A small posterior disc bulge and a left far lateral disc herniation at the L3-L4 level.

4. Slightly anteriorly wedged L1 vertebral body without signal change may be the sequelae of previous trauma.


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