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Name of the Patient : Abc Xyzed Akbar Shlmn / M / 62 yrs
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE.

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 :

The L5 vertebra is as marked on the film. Please correlate with plain radiographs.

There is scoliosis of the lumbar spine with convexity to the left and clockwise rotation of the lumbar vertebrae.

There is evidence of laminectomy at the L2 and L3 levels with post-operative changes in the posterior soft tissues.

Mild retroplacement of the L2 over the L3 and L3 over the L4 vertebrae is noted.

The lumbar intervertebral discs show loss of water content.

There is a left paracentral disc herniation with peridiscal osteophytes indenting the thecal sac and the traversing left L5 nerve root at the L4-L5 level. There is slight inferior migration of this disc.

There are posterior disc herniations with peridiscal osteophytes indenting the thecal sac and narrowing both neural foramina at the L2-L3 and L3-L4 levels. There is slight inferior migration of this disc with indentation upon the corresponding traversing nerve roots. A right far lateral disc herniation is seen at the L3-L4 level indenting the extraforaminal right L3 nerve root.

An area of intermediate signal intensity on the T1 Weighted images is seen in the right lateral recess of the L3 vertebra with encasement of the traversing right L3 nerve root. This may represent a scar tissue.

A postero-central disc extrusion with peridiscal osteophytes is seen to indent the thecal sac at the L1-L2 level. There is superior and inferior migration of this disc.

Far lateral disc herniations are seen on the right side at the L2-L3 level and on the left side at the L4-L5 level with indentation on the corresponding exiting nerve roots. A small left far lateral disc herniation is seen at the L3-L4 level. Far lateral disc bulges are seen bilaterally at the L5-S1 level, on the right side at the L4-L5 level and on the left side at the L2-L3 level.

Facetal hypertrophy is noted in the lumbar region.

The intrathecal nerve roots are clumped and irregularly defined at the L2 and L3 levels and suggest arachnoiditis.

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

The conus medullaris terminates at the L1 level and the thecal sac terminates at the S1 level.
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IMPRESSION :

1. Post-operative status.

2. Mild retroplacement of the L2 over the L3 and L3 over the L4 vertebrae.

3. A left paracentral disc herniation with peridiscal osteophytes at the L4-L5 level.

4. Posterior disc herniations with peridiscal osteophytes at the L2-L3 and L3-L4 levels.

5. A postero-central disc extrusion with peridiscal osteophytes at the L1-L2 level.

6. Far lateral disc herniations on the right side at the L2-L3 and L3-L4 levels and on the left side at the L4-L5 level.

7. Altered signal in the right lateral recess of the L3 vertebra with encasement of the traversing right L3 nerve root may represent a scar tissue.

8. Facetal hypertrophy in the lumbar region.

9. Clumped intrathecal nerve roots at the L2 and L3 levels suggest arachnoiditis.