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Name of the Patient : Abc XyzMubaralmn / F / 43 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE with paresthesias since 1 1/2 years.

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 vertebra.

There is loss of water content of the L4-L5 and L5-S1 intervertebral discs with reduction in height of these discs.

There is a small postero-central protruded disc with peridiscal osteophyte at the L5-S1 level.

There is a fairly large posterior and right postero-lateral extruded disc with peridiscal osteophytes at the L4-L5 level with thecal sac compression. Inferior migration of the disc fragment is noted into the right lateral recess of L5 indenting the traversing right L5 nerve root. Facetal and ligamentum flavum hypertrophy is also noted with canal stenosis.

A minimal posterior disc bulge is noted at the L3-L4 level.

A left far lateral peridiscal osteophyte is noted at the L2-L3 level.
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Facetal hypertrophy is noted in the lumbar region.

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 :

16.0 mm at L1-L2
15.0 mm at L2-L3
14.0 mm at L3-L4
11.0 mm at L4-L5
7.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebra.

2. A fairly large posterior and right postero-lateral extruded disc with peridiscal osteophytes at the L4-L5 level with inferior migration of the disc fragment into the right lateral recess of L5 indenting the traversing right L5 nerve root with facetal and ligamentum flavum hypertrophy with canal stenosis.

3. A small postero-central protruded disc with peridiscal osteophyte at the L5-S1 level.

4. Facetal hypertrophy in the lumbar region.


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