Date : 00.00.00
Name of the Patient : Abc Xyza Klmn / F / 58 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with radiation of pain to BLE since 2 years. H/O spinal surgery 10 years back (details not available).
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.
There is loss of water content of all the lumbar intervertebral discs except the L3-L4 disc. The L5-S1 disc is reduced in height and is dessicated and also shows presence of calcification/vacuum phenomenon.
There is evidence of laminectomy of the L3, L4 and L5 vertebrae with post-operative changes in the soft tissues in the posterior lumbar region over these levels.
There is Grade I spondylolisthesis of the L4 over the L5 and L5 over the S1 vertebrae. Resultant compromise of the neural foramen at the L4-L5 and L5-S1 levels is noted, with probable impingement of the L5 nerve roots bilaterally.
Posterior peridiscal osteophytes are noted at the L4-L5 and L5-S1 levels with bilateral neural foraminal narrowing.
Scan - 00006
Probable fusion with bone grafting is done in the L5/S1 region. The facet joints at the L5-S1 level appear hypertrophied with a posterior bony bar and canal stenosis at the L5-S1 level.
The facet joints at the L4-L5 level also appears hypertrophied.
The L5 and S1 vertebrae show fatty marrow changes.The rest of the lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12-L1 level and the thecal sac terminates at the S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
12.0 mm at L1-L2
12.0 mm at L2-L3
12.0 mm at L3-L4
1. Post-operative status with laminectomy of the L3 to L5 vertebrae and fusion with bone grafting in the L5/S1 region.
2. Grade I spondylolisthesis of the L4 over the L5 and L5 over the S1 vertebrae.
3. Posterior peridiscal osteophytes at the L4-L5 and L5-S1 levels, with bilateral neural foraminal narrowing, with impingement of the L5 nerve roots in the neural foramen bilaterally.
4. Facetal hypertrophy at the L4-L5 and L5-S1 levels with a posterior bony bar at the L5-S1 level and canal stenosis at the L4-L5 and L5-S1 levels.