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KE/bv/rg/nl

Name of the Patient : Abc XyzShlmn / F / 42 yrs.
Referred by : Dr. Abc Xyzrankar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE (left more than right) with paresthesias.

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 L3 vertebra is as marked on the film. Slight retroplacement of the L4 over the L5 vertebral body is noted.

The L4-L5 intervertebral disc shows loss of water content.

A large postero-central disc extrusion with peridiscal osteophytes is seen at the L4-L5 level with anterior compression of the thecal sac and canal stenosis. Inferior migration of the disc is noted posterior to the L5 vertebral body with thecal sac compression.

The L3-L4 and L4-L5 facet joints show degenerative changes. Effusion is noted within the right L4-L5 facet joints. Ligamentum flavum hypertrophy is noted at the L5 vertebral level.

A left far lateral disc bulge is identified at the L2-L3 level.



Type II degenerative changes are noted in the antero- superior portions of the L3, L4 and L5 vertebral bodies.

The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the 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 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

20.0 mm at L1-L2
18.0 mm at L2-L3
18.0 mm at L3-L4
10.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebral body.

2. Slight retroplacement of the L4 over the L5 vertebral body.

3. A large postero-central disc extrusion with peridiscal osteophytes at the L4-L5 level with anterior compression of the thecal sac with inferior migration of the disc posterior to the L5 vertebral body with canal stenosis.

4. Facetal arthropathy at the L3-L4 and L4-L5 levels.



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