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hs/bv/nl/nl

Name of the Patient : Abc Xyz Allmn / F / 40 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE.

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 L2 vertebra appears as marked on the film.

The lumbar intervertebral discs except the L3-L4 disc show loss of water content.

There is evidence of a large postero-central disc extrusion with peridiscal osteophytes compressing the thecal sac at the L2-L3 level.

Small posterior disc herniations are seen to indent the thecal sac and narrow both neural foramina at the L4-L5 and L5-S1 levels. The facet joints at these levels show degenerative changes.

A small left postero-lateral disc herniation is seen to narrow the left neural foramen at the L3-L4 level.

Bilateral far lateral (extraforaminal) disc bulges are noted over the L2-L3 to L5-S1 levels.




The lumbar vertebral bodies show Type II degenerative changes/spotty fatty marrow changes. The remaining 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-S2 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
13.0 mm at L2-L3
12.0 mm at L3-L4
12.0 mm at L4-L5
12.0 mm at L5-S1.

IMPRESSION :

1. A large postero-central disc extrusion with peridiscal osteophytes with canal stenosis at the L2-L3 level.

2. Small posterior disc herniations and facetal arthropathy at the L4-L5 and L5-S1 levels.

3. A small left postero-lateral disc herniation at the L3-L4 level.

4. A tight canal at the L4-L5 level.

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