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Name of the Patient : Abc Xyzd R. Adlmn / M / 42 yrs.
Referred by : Dr. Abc Xyzar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the LLE with paresthesias since 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 :

There is probable sacralization of the L5 vertebra and it is as marked on the film. Please correlate with plain radiographs.

There is mild retroplacement of the L4 over the L5 vertebrae.

There is loss of water content of the L1-L2, L4-L5 and L5-S1 intervertebral discs.

There is a small, right postero-lateral disc herniation with peridiscal osteophytes at the L5-S1 level with slight right neural foraminal narrowing.

A fairly large postero-central and left postero-lateral disc herniation with peridiscal osteophytes is noted at the L4-L5 level with left neural foraminal narrowing and indentation on the traversing left L5 nerve root. A sequestered disc fragment is noted in the anterior epidural space at the L5 vertebral level. A left far lateral (extraforaminal) disc herniation is also noted at this level.



Small, posterior and left far lateral disc bulges are noted at the L2-L3 and L3-L4 levels.

Slight facetal hypertrophy is noted in the lumbar region with ligamentum flavum hypertrophy at the L4-L5 level.

The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 S2 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

13.0 mm at L1-L2
13.0 mm at L2-L3
12.0 mm at L3-L4
9.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

1. Probable sacralization of the L5 vertebra. Please correlate with plain radiographs.

2. A small, right postero-lateral disc herniation with peridiscal osteophytes at the L5-S1 level.

3. A fairly large postero-central and left postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with indentation on the traversing left L5 nerve root. A sequestered disc fragment is noted in the anterior epidural space at the L5 vertebral level.
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4. A left far lateral (extraforaminal) disc herniation at the L4-L5 level.

5. Slight facetal hypertrophy in the lumbar region with ligamentum flavum hypertrophy at the L4-L5 level.

6. Canal stenosis at the L4-L5 level.

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