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Name of the Patient : Abc Xyzen B. Plmn / F / 68 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Dorso-lumbar Spine.
CLINICAL PROFILE :
C/O weakness of the LLE with foot drop since 2 days.
EXAMINATION :
M.R.I of the dorso-lumbar 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 L5 vertebral body in relation to S1 and slight forward translation of the L4 over the L5 vertebra without obvious spondylolysis.
There is reduction in height and loss of water content of the visualized dorso-lumbar intervertebral discs. Some of these discs show evidence of calcium/vacuum phenomena.
Posteriorly herniated discs with peridiscal osteophytes are noted at the L4-L5 and L5-S1 levels with bilateral neural foraminal narrowing. Impingement of the L5 nerve roots bilaterally and the right L4 nerve root in their corresponding neural foramen is noted. There is hypertrophic facetal arthropathy and ligamentum flavum hypertrophy at the L4-L5 level with canal stenosis. Facetal arthropathy is also noted at the L5-S1 level.
Posteriorly bulging discs with peridiscal osteophytes are noted at the L1-L2, L2-L3 and L3-L4 levels. Facetal and ligamentum flavum hypertrophy is noted at the L2-L3 and L3-L4 levels with resultant canal stenosis at these levels.
Facetal hypertrophy is also noted D10-D11 and D11-D12 levels.
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Anterior disc herniations with anterior peridiscal osteophytes are noted in the dorso-lumbar region.
The visualized dorso-lumbar vertebral bodies reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The visualized lower dorsal spinal cord reveals normal signal intensity.
The conus medullaris terminates at the L1-L2 level and thecal sac terminates at S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
14.0 mm at L1-L2
14.0 mm at L2-L3
12.0 mm at L3-L4
12.0 mm at L4-L5
13.0 mm at L5-S1.
Screening T2 Weighted sagittal images of the upper dorsal spinal cord do not reveal any significant feature of note.
IMPRESSION :
1. Slight retroplacement of the L5 vertebral body in relation to S1 and slight forward translation of the L4 over the L5 vertebra without obvious spondylolysis.
2. Posteriorly herniated discs with peridiscal osteophytes at the L4-L5 and L5-S1 levels with impingement of the L5 nerve roots bilaterally and the right L4 nerve root in their corresponding neural foramen.
3. Hypertrophic facetal arthropathy and ligamentum flavum hypertrophy at the L4-L5 level and facetal arthropathy at the L5-S1 level.
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4. Posteriorly bulging discs with peridiscal osteophytes at the L1-L2, L2-L3 and L3-L4 levels with facetal and ligamentum flavum hypertrophy at the L2-L3 and L3-L4 levels.
5. Facetal hypertrophy D10-D11 and D11-D12 levels.
6. Lumbar canal stenosis, maximum at the L2-L3, L3-L4 and L4-L5 levels.