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ke/bv/nl/rg.

Name of the Patient : Abc Xyz K. Thlmn / F / 60 yrs.
Referred by : Dr. Abc Xyz Taraporewala /
Dr. Abc Xyzeshmukh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O low back pain with pain radiating to the LLE.

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 sacralization of the L5 vertebra which is as marked on this film.

The lumbar intervertebral discs show loss of water content and the L1-L2 disc is reduced in height.

There is a diffuse posterior disc herniation at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L4-L5 facet joints show hypertrophic degenerative changes. Minimal fluid is noted in the facet joints bilaterally. There is resultant tight lumbar canal at this level.

A small posterior and a right far lateral disc herniation is seen at the L5-S1 level with mild indentation upon the extraforaminal portion of the right L5 nerve root.

A posterior disc herniation with peridiscal osteophytes is noted at the L1-L2 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing.

There is a posterior and a right far lateral disc bulge at the L3-L4 level. ..2/.




Focal fatty changes are noted in the lumbar vertebrae.

The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12 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 :

14.0 mm at L1-L2
17.0 mm at L2-L3
13.0 mm at L3-L4
11.0 mm at L4-L5
12.0 mm at L5-S1.

IMPRESSION :

1. A diffuse posterior disc herniation with hypertrophic facetal arthropathy and minimal fluid in the facet joints, bilaterally at the L4-L5 level with resultant tight lumbar canal.

2. A posterior disc herniation with peridiscal osteophytes at the L1-L2 level.



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