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Name of the Patient : Abc Xyzi Jalmn / M / 57 yrs.
Referred by : Dr. Abc Xyzlkarni.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE since 15 days.

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 reduction in the height of the D10-D11, L2-L3, L3-L4 and L4-L5 intervertebral discs and loss of water content of the lumbar and the lower dorsal intervertebral discs.

There is slight retroplacement of the L3 over the L4, L4 over the L5 and L5 over the S1 vertebral body.

A posterior and a left postero-lateral disc herniation with posterior peridiscal osteophytes is seen at the L5-S1 level level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. There is resultant indentation upon the traversing left S1 nerve root and the foraminal portion of the L5 nerve roots bilaterally. There is probable conjoint nerve root on the left side at the L5 level. Mild facetal and ligamentum flavum hypertrophy is also seen at this level.

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A posterior disc herniation is seen at the L4-L5 level with anterior compression of the thecal sac and bilateral neural foraminal narrowing. Slight inferior migration of the disc is noted with indentation upon the L5 nerve roots bilaterally, more on the right side. Mild facetal hypertrophy is seen at these levels.

A left far lateral disc herniation is also noted at the L4-L5 level with indentation upon the extraforaminal portion of the exiting left L4 nerve root.

There is a small posterior disc herniation with peridiscal osteophytes at the L3-L4 level with anterior indentation of the thecal sac. A right far lateral disc bulge is also seen at this level.

There is a small posterior and a left far lateral disc herniation with posterior peridiscal osteophytes at the L2-L3 level and mild indentation upon the exiting left L2 nerve root.

There is suggestion of a conjoint nerve root on the right side at the S1 level.

The L3-L4 facet joints on the right show degenerative changes with resultant lateral canal stenosis at L2-L3, L3-L4 and L4-L5 levels.

Anterior peridiscal osteophytes are seen in the lumbar region.

Slight anterior wedging of the D11 vertebral body is noted. Type II degenerative changes and diffuse fatty changes are seen in the lower dorsal and the lumbar vertebrae.
Type I degenerative change is seen in the L2 vertebral body adjacent to the L2-L3 intervertebral disc.

The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
..3/.





- 3 - Scan-00007

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 :

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

IMPRESSION :

1. Slight retroplacement of the L3 over the L4, L4 over
the L5 and L5 over the S1 vertebral body.

2. A posterior disc herniation at the L4-L5 level with slight inferior migration of the disc with indentation upon the L5 nerve roots bilaterally, more marked on the right side with a left far lateral disc herniation at the L4-L5 level with indentation upon the extraforaminal portion of the exiting left L4 nerve root.

3. A posterior and a left postero-lateral disc herniation with posterior peridiscal osteophytes at the L5-S1 level with resultant indentation upon the traversing left S1 nerve root and the foraminal portion of the L5 nerve roots bilaterally.

4. A small posterior disc herniation with peridiscal osteophytes at the L3-L4 level.

5. A small posterior and a left far lateral disc herniation with posterior peridiscal osteophytes at the L2-L3 level and mild indentation upon the exiting left L2 nerve root.
..4/.







- 4 - Scan-00007

6. Facetal hypertrophy at the L4-L5 and L5-S1 levels
bilaterally and facetal arthropathy on the right side at the L3-L4 level.

7. Tight canal at the L2-L3, L3-L4 and L4-L5 levels.