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Name of the Patient : Abc Xyzen Jlmn / F / 67 yrs.
Referred by : Dr. Abc Xyzmpat.
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 :

There is sacralization of the L5 vertebral body and the L2 vertebra is as marked on the film. There is slight scoliosis of the lumbar spine with convexity to the left and mild clockwise rotational anomaly of the upper lumbar vertebral bodies.

A posterior disc herniation with peridiscal osteophyte is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. Slight facetal hypertrophy is noted.

There is slight forward translation of the L3 over the L4 vertebral body. A posterior and bilateral far lateral disc bulge is seen at the L3-L4 level with bilateral neural formainal narrowing. The L3-L4 facet joints show hypertrophic degenerative changes with minimal effusion. There is also ligamentum flavum hypertrophy and resultant central and lateral canal stenosis.

A small posterior and left far lateral disc bulge is noted at the L2-L3 level. Anterior disc herniations with peridiscal osteophytes are seen at the L2-L3, L3-L4 and L4-L5 levels. The lumbar intervertebral discs show loss of water content.
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Type II degenerative changes are noted in the L4 and L5 vertebral bodies adjacent to the L4-L5 intervertebral disc.

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 D12 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 :

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

The left kidney appears small and would require further evaluation.

IMPRESSION :

1. Sacralization of the L5 vertebral body.

2. A posterior disc herniation with peridiscal osteophyte at the L4-L5 level with slight facetal hypertrophy.

3. Forward translation of the L3 over the L4 vertebral body with a posterior and bilateral far lateral disc bulge at the L3-L4 level with bilateral neural formainal narrowing. There is hypertrophic facetal arthropathy with minimal effusion and ligamentum flavum hypertrophy with resultant central and lateral canal stenosis.

4. A small posterior and left far lateral disc bulge at the L2-L3 level.


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