sb/ke/rg/nl
Name of the Patient : Abc XyzS. Dlmn / M / 51 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 with paresthesias since 4 months.
H/O laminectomy with discectomy at L2-L3 level in 0000.
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 water content of the L2-L3, L3-L4 and L4-L5 intervertebral discs.
There is evidence of laminectomy at the L2 vertebral level and L2-L3 discectomy with post-operative changes in the soft tissues in the posterior lumbar region at this level. Slight kyphus is noted at the L2/L3 level.
There is slight retroplacement of the L4 over the L5 and L3 over L4 vertebrae.
There is a postero-central disc herniation with peridiscal osteophytes at the L4-L5 level indenting the dural theca anteriorly. A left far lateral disc herniation is also noted at this level indenting the extraforaminal portion of the left L4 nerve root.
Scan-00002
There is a posterior disc bulge with peridiscal osteophyte at the L3-L4 level with a left far lateral disc herniation at this level indenting the extraforaminal segment of the left L3 nerve root.
An osteophyte is noted along the postero-inferior margin of the L2 vertebral body indenting the dural theca anteriorly.
Facetal hypertrophy is noted at the L5-S1 level on the right and at the L3-L4 and L4-L5 levels bilaterally.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 :
19.0 mm at L1-L2
18.0 mm at L3-L4
15.0 mm at L4-L5
18.0 mm at L5-S1.
Screening T2 Weighted sagittal and T1 Weighted axial images of the cervical spine reveal right postero-lateral disc herniations with peridiscal osteophytes at the C4-C5 and C5-C6 levels and a small posterior peridiscal osteophyte at the C3-C4 level.
..3/.
- 3 - Scan-00002
IMPRESSION :
1. Post-operative status.
2. Slight retroplacement of the L4 over the L5 and L3 over L4 vertebrae.
3. A postero-central and a left far lateral
disc herniation with peridiscal osteophytes at the L4-L5 level indenting the extraforaminal portion of the left L4 nerve root.
4. A posterior disc bulge with peridiscal osteophyte at the L3-L4 level with a left far lateral disc herniation at this level indenting the extraforaminal segment of the left L3 nerve root.
5. An osteophyte along the postero-inferior margin of the L2 vertebral body.
6. Facetal hypertrophy at the L5-S1 level on the right and at the L3-L4 and L4-L5 levels bilaterally.
7. Right postero-lateral disc herniations with peridiscal osteophytes at the C4-C5 and C5-C6 levels. If clinically indicated, a dedicated study of the cervical spine would be worthwhile.