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Name of the Patient : Abc Xyza Assad Mlmn / M / 75 yrs.
Referred by : Dr. Abc Xyzcha.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE since 3 months.
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 loss of normal lumbar lordosis and loss of water content of the lumbar intervertebral discs. The D12-L1 intervertebral disc is reduced in height.

There is a posterior disc bulge and a right postero-lateral (foraminal) disc protrusion at the L5-S1 level with right neural foraminal narrowing and indentation on the traversing right S1 nerve root. Facetal hypertrophy is noted at this level.

There is a posteriorly herniated disc at the L4-L5 level with bilateral neural foraminal narrowing. Facetal and ligamentum flavum hypertrophy is also noted at this level with resultant canal stenosis. There is indentation on the traversing left L5 nerve root at the L5 vertebral level (Scan 104.6).

There is a posteriorly herniated disc at the L3-L4 level, with bilateral neural foraminal narrowing, more on the right side. A sequestered disc fragment is noted in the right lateral recess of L4, impinging the traversing right L4 nerve root. There is also facetal and ligamentum flavum hypertrophy with canal stenosis.
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Left and right postero-lateral disc herniations are noted at the L2-L3 level with bilateral neural foraminal narrowing and facetal hypertrophy at that level.

A left far lateral disc herniation with peridiscal osteophytes is noted at the L1-L2 level with minimal indentation on the left L1 nerve root.

A posterior disc bulge with peridiscal osteophytes is noted at the D12-L1 level with thecal sac compression and a tight canal at that level.

There is central and anterior wedging of the L4 vertebral body without change in signal intensity.

The lumbar vertebral bodies show spotty fatty marrow changes. The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12-L1 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 :

7.0 mm at D12-L1
13.0 mm at L1-L2
15.0 mm at L2-L3
9.0 mm at L3-L4
15.0 mm at L4-L5
16.0 mm at L5-S1.

Screening, T2 Weighted sagittal images of the dorsal spine reveal wedging of the D7 vertebral body with slight facetal hypertrophy in the mid and lower dorsal regions.

Incidentally noted is mild hepatosplenomegaly and a cortical renal cyst at the inferior pole of the right kidney.
..3/.








- 3 - Scan-00002

IMPRESSION :

1. A posterior disc bulge with a right postero-lateral (foraminal) disc protrusion at the L5-S1 level indenting the traversing right S1 nerve root with facetal hypertrophy at this level.

2. A posteriorly herniated disc at the L4-L5 level with facetal and ligamentum flavum hypertrophy and canal stenosis and indentation on the traversing left L5 nerve root at the L5 vertebral level.

3. A posteriorly herniated disc at the L3-L4 level, with a sequestered disc fragment in the right lateral recess of L4, indenting the traversing right L4 nerve root with facetal and ligamentum flavum hypertrophy and canal stenosis at that level.

4. Left and right postero-lateral disc herniations at the L2-L3 level with facetal hypertrophy at that level.

5. A left far lateral disc herniation with peridiscal osteophytes at the L1-L2 level with minimal indentation on the left L1 nerve root.

6. A posterior disc bulge with peridiscal osteophytes at the D12-L1 level with a tight canal at that level.

7. Central and anterior wedging of the L4 and the D7 vertebral bodies as described may be the sequelae of previous trauma.

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