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Name of the Patient : Abc Xyzi K. Pilmn / F / 53 yrs.
Referred by : Dr. Abc Xyzrani.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with paresthesias in 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 nearly all the lumbar intervertebral discs except the L5-S1 disc.

There is a posteriorly herniated disc with a peridiscal osteophyte at the L4-L5 level with thecal sac compression and bilateral neural foraminal narrowing. Facetal and ligamentum flavum hypertrophy is noted at this level with canal stenosis.

A small, left postero-lateral disc bulge with peridiscal osteophyte is noted at the L3-L4 level.

Facetal hypertrophy is noted at the L2-L3, L3-L4 and L5-S1 levels.

The lumbar vertebral bodies reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.



The conus medullaris terminates at the L1-L2 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 :

16.0 mm at L1-L2
16.0 mm at L2-L3
13.0 mm at L3-L4
6.0 mm at L4-L5
8.0 mm at L5-S1.

Screening, T2 Weighted sagittal images of the cervical spine reveals fusion of the C4 and C5 vertebral bodies with postero-central protruded discs with peridiscal osteophytes at the C3-C4 and C5-C6 levels. Focal hyperintense signal on the T2 Weighted images in the cervical spinal cord at the C4-C5 disc level may represent myelomalacic changes.

IMPRESSION :

1. A posteriorly herniated disc with a peridiscal osteophyte at the L4-L5 level with facetal and ligamentum flavum hypertrophy and canal stenosis.

2. A small, left postero-lateral disc bulge with peridiscal osteophyte at the L3-L4 level.

3. Facetal hypertrophy at the L2-L3, L3-L4 and L5-S1 levels.

4. Post-operative changes in the cervical spine with focal altered signal in the cervical spinal cord at the C4-C5 disc level which may represent myelomalacic changes.

If clinically indicated a dedicated study of the cervical spine would be worthwhile.

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