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Name of the Patient : Abc Xyz Triplmn / M / 23 yrs.
Referred by : Dr. Abc Xyzwant.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE with paresthesias since 4-5 years.
Alleged H/O fall in 0000.

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 the L3-L4 and L5-S1 intervertebral discs.

There is S shaped scoliosis of the dorso-lumbo-sacral spine.

There is slight retroplacement of the L3 vertebra over the L4 vertebra.

There is a hemivertebra at the L5 level with the right half of the L5 vertebra well-identified on this study. Spina bifida is noted at the L4, L5 and S1 vertebral levels.
Anti-clockwise rotational anomaly of L4 and L5 vertebrae is noted.

There is a small posterior disc herniation at the L5-S1 level more to the right of the midline.

A small postero-central disc herniation with peridiscal osteophytes is seen at the L3-L4 level with a right far lateral disc bulge at that level.
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Facetal hypertrophy is noted at the L5-S1 and L4-L5 levels on the right with slight ligamentum flavum hypertrophy at these levels.

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 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 :

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

IMPRESSION :

1. S shaped scoliosis of the dorso-lumbo-sacral spine.

2. Slight retroplacement of the L3 vertebra over the L4 vertebra.

3. A hemivertebra at the L5 level.

4. Spina bifida at the L4, L5 and S1 vertebral levels with anti-clockwise rotational anomaly of the L4 and L5 vertebrae.

5. A small posterior disc herniation at the L5-S1 level, more to the right of the midline.

6. A small postero-central disc herniation with peridiscal osteophytes at the L3-L4 level with a right far lateral disc bulge at that level.

7. Facetal hypertrophy at the L5-S1 and L4-L5 levels on the right with slight ligamentum flavum hypertrophy at these levels.
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