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Name of the Patient : Abc Xyz Katlmn / M / 64 yrs.
Referred by : Dr. Abc Xyzonawalla.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE with paresthesias since 0000.

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 loss of water content of the lumbar intervertebral discs.

Minimal forward translation of the L4 over the L5 vertebra is noted without obvious spondylolysis.

There is a small, postero-central protruded disc at the L5-S1 level with slight facetal hypertrophy at that level.

A posteriorly bulging disc is noted at the L4-L5 level with slight right neural foraminal narrowing. Slight superior migration of the disc fragment is noted in the right neural foramen at the L4-L5 level with impingement of the exiting right L4 nerve root. Hypertrophic facetal hypertrophy is noted at this level with ligamentum flavum hypertrophy and canal stenosis. Mild facet joints effusion is noted at the L4-L5 level.

Left and right postero-lateral disc bulges are noted at the L3-L4 level with bilateral neural foraminal narrowing.
..2/.





>
Left and right postero-lateral disc bulges and a right far lateral disc herniation with peridiscal osteophyte is noted at the L2-L3 level.

A small posterior disc bulge is noted at the L1-L2 level with a right far lateral disc herniation with peridiscal osteophytes at that level.

Small posterior peridiscal osteophytes are noted at the D11-D12 and D12-L1 levels with a right paracentral protruded disc at the D12-L1 level. Anterior peridiscal osteophytes are seen in the lumbar region.

There is slight anterior wedging of the D12 vertebral body and central wedging of the L3 vertebral body. These vertebrae appear hypointense on the T1 Weighted images in their superior portion and hyperintense on the T2 Weighted images. Compressed trabeculae are noted along the superior cortical endplate of D12 vertebra which are hypointense on all the pulse sequences. There is central herniation of the L2-L3 disc into the body of the L3 vertebra.

The rest of the lumbar vertebral bodies show fatty marrow changes suggesting osteoporosis.

The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the 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 :

15.0 mm at L1-L2
15.0 mm at L2-L3
15.0 mm at L3-L4
10.0 mm at L4-L5
13.0 mm at L5-S1.
..3/.








- 3 - Scan-00006


IMPRESSION :

1. Minimal forward translation of the L4 over the L5
vertebra without obvious spondylolysis.

2. A small, postero-central protruded disc at the L5-S1 level with slight facetal hypertrophy at that level.

3. A posteriorly bulging disc at the L4-L5 level with slight superior migration of the disc fragment in the right neural foramen at the L4-L5 level with impingement of the exiting right L4 nerve root. Hypertrophic facetal hypertrophy and ligamentum flavum hypertrophy is noted with canal stenosis at this level.

4. Left and right postero-lateral disc bulges at the L3-L4 level with bilateral neural foraminal narrowing.

5. A small posterior disc bulge at the L1-L2 level with a right far lateral disc herniation with peridiscal osteophytes at that level.

7. Anterior wedging of the D12 vertebral body and central wedging of the L3 vertebral body with altered signal most likely represent compression fracture superimposed on osteoporotic vertebrae. The rest of the lumbar vertebral bodies show fatty marrow changes suggesting osteoporotic changes.


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