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sb/ke/nl/nl

Name of the Patient : Abc Xyzlmn / F / 37 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE since 2 months.

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 mild retroplacement of the L5 vertebra over the S1 vertebra. The L5-S1 intervertebral disc shows loss of water content.

A large postero-central disc extrusion with peridiscal osteophytes is seen to compress the thecal sac at the L5-S1 level. An extruded disc portion, more to the right of the midline is seen within the anterior epidural space at the S1 vertebral level. Also seen is indentation upon the traversing S1 and S2 nerve roots, right more than left.

There is mild facetal hypertrophy at the L5-S1 level.

A mild posterior disc bulge is noted at the L4-L5 level.

Type II degenerative changes are seen within the L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral disc.

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.
..2/.






- 2 - Scan-00001


The conus medullaris terminates at the L1-L2 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 :

19.0 mm at L1-L2
21.0 mm at L2-L3
20.0 mm at L3-L4
17.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of a large postero-central disc extrusion with peridiscal osteophytes at the L5-S1 level with an extruded disc portion, more to the right of the midline lying within the anterior epidural space at the S1 vertebral level.

As compared to the previous MRI (study no:00003) dated : 00.00.0000, there is no significant change noted.


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    • Million Muskmelons
    • Interventional Pain Procedure Templates
    • The Ultimate Guide to Rapid Reporting for FRCR 2B
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