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ke/hs/rg/nl

Name of the Patient : Abc XyzK. Gillmn / M / 45 yrs.
Referred by : Dr. Abc Xyzar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the LLE with paresthesias since 4-5 months.
H/O lifting heavy weight.

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 a large postero-central disc herniation with peridiscal osteophytes at the L5-S1 level with anterior indentation of the thecal sac. Superior migration of the disc portion (? free fragment) is noted into the anterior epidural space at the L5 vertebral level.

A diffuse posterior disc herniation with posterior peridiscal osteophytes, more to the left is noted at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing.

Mild facetal hypertrophy is seen in the lumbar region.

The L4-L5 and L5-S1 intervertebral discs show loss of water content.

Type II degenerative changes are seen in the L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral disc.
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The rest of 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 D12-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 :

15.0 mm at L1-L2
14.0 mm at L2-L3
14.0 mm at L3-L4
12.0 mm at L4-L5
9.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. A large postero-central disc herniation with peridiscal osteophytes at the L5-S1 level with superior migration of the disc portion (? free fragment) which is lying in the anterior epidural space at the L5 vertebral level.

2. A diffuse posterior disc herniation with posterior peridiscal osteophytes at the L4-L5 level.

3. Mild facetal hypertrophy in the lumbar region.

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