DUPLICATE COPY ke.hs.rg
Name of the Patient : Abc XyzGolmn / M / 64 yrs.
Referred by : Dr. Abc Xyzravle.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE since 2-3 years.
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 slight forward translation of the L4 vertebra over the L5 vertebra.
There is a 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 with ligamentum flavum hypertrophy and a resultant tight canal.
A small posterior disc bulge and a left postero-lateral lateral disc herniations are seen at the L3-L4 level with anterior indentation of the thecal sac and mild left neural foraminal narrowing, respectively. The L3-L4 facet joints show mild degenerative changes.
A postero-central disc herniation with peridiscal osteophytes is noted at the L5-S1 level. Bilateral far lateral disc bulges are seen at this level with slight indentation upon the extraforaminal portion of the exiting right L5 nerve root. Facetal hypertrophy is noted at the L5-S1 level.
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- 2 - Scan-00002
Far lateral disc bulges are seen on the left at the L3-L4 level and on the right at the L2-L3 level.
There are anterior disc herniations in the lumbar region. The L2-L3 to L5-S1 intervertebral discs show loss of water content.
A probable hemangioma with fat content is seen in the L4 vertebral body. Fattty changes are noted in the lumbar vertebral bodies and visualized lower dorsal vertebrae.
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 :
16.0 mm at L1-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
13.0 mm at L4-L5
15.0 mm at L5-S1.
IMPRESSION :
The MRI features are suggestive of :
1. Slight forward translation of the L4 vertebra over the L5 vertebra.
2. A posterior disc herniation at the L4-L5 level with hypertrophic facetal arthropathy with ligamentum flavum hypertrophy and a resultant tight canal at this level.
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- 3 - Scan-00002
3. A small posterior disc bulge and a left postero-lateral disc herniation at the L3-L4 level.
4. A postero-central disc herniation with peridiscal osteophytes at the L5-S1 level. Bilateral far lateral disc bulges are seen at this level with slight indentation upon the extraforaminal portion of the exiting right L5 nerve root.