sb/hs/rg.
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Name of the Patient : Abc Xyzishna Ralmn / M / 51 yrs.
Referred by : Dr. Abc Xyzrani.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE with paresthesias since October 0000.
Past H/O left sided L2-L3 and right sided L3-L4 disc surgery in January 0000. Details not available.
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.
After administration of contrast, 5 mm thick T1 Weighted sagittal and axial images (with fat saturation) and 3 mm thick T1 Weighted coronal images (with fat saturation) were obtained.
The cervico-dorsal region was also screened with 5 mm thick T1 Weighted sagittal images (with fat saturation).
OBSERVATION :
There is H/O left sided L2-L3 and right sided L3-L4 disc surgery, the details of which are not available.
There is loss of water content of nearly all the lumbar intervertebral discs except the L5-S1 intervertebral discs.
There is minimal forward translation of the L5 vertebra over the S1 vertebra without obvious spondylolysis.
There is a small, postero-central disc herniation at the L5-S1 level.
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There is a small, posterior disc bulge with a right postero-lateral (foraminal) protruded disc at the L4-L5 level with slight right neural foraminal narrowing.
A left and right postero-lateral disc herniation is noted at the L3-L4 level with bilateral neural foraminal narrowing. There is indentation on the traversing right L4 nerve root at this level.
Facetal hypertrophy is noted in the lumbar region with slight ligamentum flavum hypertrophy at the L3-L4 and L4-L5 levels.
After administration of contrast, there is slight enhancement of the intrathecal nerve roots at the L5 and S1 vertebral levels. No obvious meningeal enhancement is noted on this study.
The lumbar vertebral bodies reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
A Tarlovs perineurial cyst is noted in the sacral canal at the S1-S2 level.
The conus medullaris terminates at the L1 level and the thecal sac terminates at the S1 level.
Screening of the cervico-dorsal spine, after contrast administration does not reveal any significant features of note.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
19.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
13.0 mm at L4-L5
9.0 mm at L5-S1.
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- 3 - Scan-00000
IMPRESSION :
1. Minimal forward translation of the L5 vertebra over the S1 vertebra without obvious spondylolysis.
2. A small, postero-central disc herniation at the L5-S1 level.
3. A small, posterior disc bulge with a right postero-lateral (foraminal) protruded disc at the L4-L5 level with slight right neural foraminal narrowing.
4. A left and right postero-lateral disc herniation at the L3-L4 level with bilateral neural foraminal narrowing and indentation on the traversing right L4 nerve root at this level.
5. Facetal hypertrophy in the lumbar region with slight ligamentum flavum hypertrophy at the L3-L4 and L4-L5 levels.
6. Enhancement of the intrathecal nerve roots at the L5 and S1 vertebral levels (? arachnoiditis).
The patient is status post-operative, the details of which are not available.