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hs/ke/nl/rg.

Name of the Patient : Abc Xyz G. Shilmn / M / 35 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE (right more than left) 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 slight retroplacement of the L3 over the L4 and of the L4 over the L5 vertebrae. The lumbar intervertebral discs except at the L2-L3 level show loss of water content.

Posterior disc herniations are seen to indent the thecal sac and narrow both neural foramina at the L3-L4 and L4-L5 levels. The facet joints at these levels show hypertrophic degenerative changes.

A small right postero-lateral and right far lateral disc herniation is seen at the L5-S1 level with slight right neural foraminal narrowing at this level.

There is a mild posterior disc bulge at the L2-L3 level. There is an anterior disc herniation with peridiscal osteophytes at the L1-L2 level.

Bilateral far lateral (extraforaminal) disc bulges are noted at the L3-L4, L4-L5 and L5-S1 levels. There is facetal hypertrophy at the L1-L2, L2-L3 and L5-S1 levels.
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The lumbar vertebral bodies show Type II degenerative changes.

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 :

12.0 mm at L1-L2
11.0 mm at L2-L3
9.0 mm at L3-L4
8.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. Posterior disc herniations and hypertrophic facetal arthropathy with resultant canal stenosis at the L3-L4 and L4-L5 levels.

2. A small right postero-lateral and right far lateral disc herniation at the L5-S1 level.

3. Facetal hypertrophy at the L1-L2, L2-L3 and L5-S1 levels.

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