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Name of the Patient : Abc Xyzoxlmn / F / 72 yrs.
Referred by : Dr. Abc XyzBhojraj.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE with paresthesias.

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 lumbar intervertebral discs with reduction in height of the L3-L4 and L4-L5 intervertebral discs.

There is probable sacralization of the L5 vertebra. There is minimal forward translation of the L3 vertebra over the L4 vertebra without obvious spondylolysis.

There is a small posterior disc herniation at the L5-S1 level with slight facetal and ligamentum flavum hypertrophy at that level.

A posterior and right postero-lateral disc herniation with peridiscal osteophytes is noted at the L4-L5 level with right neural foraminal narrowing. Facetal hypertrophy is also noted at this level.

A small, posterior disc bulge is noted at the L3-L4 level with hypertrophic facetal arthropathy and ligamentum flavum hypertrophy at this level with resultant canal stenosis. Facet joint effusion is noted at this level. Also seen is a right far lateral disc bulge at this level.
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Hypertrophic facetal arthropathy is noted at the L1-L2 and L2-L3 levels.

The lumbar vertebral bodies reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1 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
11.0 mm at L2-L3
8.0 mm at L3-L4
8.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. Probable sacralization of the L5 vertebra with minimal forward translation of the L3 vertebra over the L4 vertebra without obvious spondylolysis.

2. A small posterior disc herniation at the L5-S1 level with slight facetal and ligamentum flavum hypertrophy at this level.

3. A posterior and right postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with facetal hypertrophy at this level.

4. A small, posterior disc bulge with hypertrophic facetal arthropathy and ligamentum flavum hypertrophy at the L3-L4 level with resultant canal stenosis.

5. Hypertrophic facetal arthropathy at the L1-L2 and L2-L3 levels.


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