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Name of the Patient : Abc Xyza Yusuf Ylmn / F / 35 yrs.
Referred by : Dr. Abc Xyzrma.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O low back pain since 3 years, radiating to the LLE.

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 L3-L4 and L4-L5 intervertebral discs.

There is a left paracentral disc herniation with peridiscal osteophytes at the L5-S1 level and left neural foraminal narrowing. Facetal hypertrophy and mild ligamentum flavum hypertrophy is noted at this level.

There is a fairly large, posteriorly extruded disc with peridiscal osteophytes at the L4-L5 level, thecal sac compression and bilateral neural foraminal narrowing. Inferior migration of the disc is seen lying posterior to the L4 vertebral body (se/im:106/5). Facetal and ligamentum flavum hypertrophy is noted with a tight canal.

A small posterior disc bulge with peridiscal osteophytes is noted at the L3-L4 level.

Slight facetal hypertrophy is seen at the L1-L2, L2-L3 and L3-L4 levels.



Schmorls nodes are noted in the lower lumbar region.

There are Type II degenerative marrow changes adjacent to the L3-L4 and L4-L5 discs.

The rest of 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 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 :

17.0 mm at L1-L2
18.0 mm at L2-L3
15.0 mm at L3-L4
10.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. A left paracentral disc herniation with peridiscal osteophytes at the L5-S1 level, with facetal hypertrophy at that level.

2. A fairly large, posteriorly extruded disc with peridiscal osteophytes at the L4-L5 level, with facetal and ligamentum flavum hypertrophy and canal stenosis.

3. A small posterior disc bulge with peridiscal osteophytes at the L3-L4 level.


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