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Name of the Patient : Abc Xyz D. Palmn / F / 70 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 with paresthesias since 2 years.
Alleged H/O fall.

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 scoliosis of the lumbar spine with convexity to the left.

The lumbar intervertebral discs show loss of water content and the L2-L3, L3-L4 and L4-L5 intervertebral discs are decreased in height. The L2-L3 to L5-S1 intervertebral discs show hypointense area on all the pulse sequences and this may represent calcium/vacuum phenomena.

Posterior disc herniations with peridiscal osteophytes are seen to indent the thecal sac and narrow both neural foramina at the L2-L3, L3-L4, L4-L5 and L5-S1 levels. Also seen is indentation upon the exiting nerve roots within the neural foramina at these levels. Also seen are bilateral far lateral (extraforaminal) disc herniations with peridiscal osteophytes at these levels.

The L5-S1 facet joints show hypertrophic degenerative changes (left more than right). The rest of the lumbar facet joints also show degenerative changes.
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Bilateral postero-lateral and far lateral disc herniations with peridiscal osteophytes are seen to narrow both neural foramina at the L1-L2 level.

The pedicles of the lumbar vertebrae appear congenitally short in their antero-posterior dimensions.

Type II degenerative changes are seen within the lumbar vertebral bodies and the S1 vertebral body.

Anterior disc herniations with peridiscal osteophytes are noted over the L1-L2 to the L5-S1 levels.

The visualized paraspinal and psoas muscles in the lumbo-sacral region are atrophic.

The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the 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 :

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

IMPRESSION :

1. Posterior and bilateral far lateral (extraforaminal) disc herniations with peridiscal osteophytes at the L2-L3, L3-L4, L4-L5 and L5-S1 levels.

2. Bilateral postero-lateral and far lateral disc herniations with peridiscal osteophytes at the L1-L2 level.
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3. Severe hypertrophic facetal arthropathy at the L5-S1 level (left more than right) with facetal arthropathy
in the rest of the lumbar region.

4. Tight lumbar canal with scoliosis of the lumbar spine with convexity to the left.

5. Congenitally short pedicles of the lumbar vertebrae in their antero-posterior dimensions.


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