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Name of the Patient : Abc Xyz Vlmn / M / 65 yrs.
Referred by : Dr. Abc XyzV. Shah.
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 loss of water content of the lumbar intervertebral discs.

There is a posteriorly herniated disc with peridiscal osteophytes at the L5-S1 level with bilateral neural foraminal narrowing and indentation on the traversing right S1 nerve root. The exiting L5 nerve roots are impinged in the neural foramen at the L5-S1 level. There is facetal and ligamentum flavum hypertrophy at the L5-S1 level with canal stenosis.

A small posterior disc bulge with peridiscal osteophytes is noted at the L4-L5 level, with bilateral neural foraminal narrowing. There is facetal hypertrophy at this level.

Small posterior disc bulges with peridiscal osteophytes are noted at the L2-L3 and L3-L4 levels.

A small, left paracentral protruded disc with peridiscal osteophytes is noted at the L1-L2 level.

Anterior disc herniations with anterior peridiscal osteophytes are noted in the lumbar region with a probably fractured osteophyte along the antero-superior margin of the L5 vertebral body.

Type II degenerative marrow changes are noted at the L4-L5 and L5-S1 intervertebral discs.

The lumbar vertebral bodies show spotty fatty marrow changes. The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L2 level and the thecal sac terminates at the S3 level.

The sacral nerve roots show evidence of baggy nerve root sleeves.

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

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

IMPRESSION :

1. A posteriorly herniated disc with peridiscal osteophytes at the L5-S1 level with bilateral neural foraminal narrowing and indentation on the traversing right S1 nerve root with impingement of the L5 nerve roots in the neural foramen bilaterally. There is also facetal and ligamentum flavum hypertrophy with canal stenosis.
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2. A small posterior disc bulge with peridiscal osteophytes at the L4-L5 level, with facetal hypertrophy.

3. Small posterior disc bulges with peridiscal osteophytes at the L2-L3 and L3-L4 levels.

4. A small, left paracentral protruded disc with peridiscal osteophytes at the L1-L2 level.


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