Date : 00.00.00
Name of the Patient : Abc XyzKlmn / F / 69 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with numbness since 2 weeks. Also C/O weakness of the RLE since 2 days.
H/O L4-L5 laminectomy done on 00.00.00.
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 are post-operative changes in the posterior soft tissues over the L4 to S1 levels with laminectomy of the L4 and L5 vertebrae.
Slight forward subluxation of the L4 over the L5 vertebra is noted.
A large, right paracentral and postero-lateral disc extrusion is seen at the L4-L5 level with antero-lateral compression of the thecal sac and right neural foraminal narrowing. There is superior migration of the disc which is seen to lie in the right lateral recess of the L4 vertebra with impingement of the traversing right L4 nerve root. There is suggestion of inflammation of the right L5 nerve root.
Small posterior disc bulge with a posterior peridiscal osteophyte is noted at the L2-L3 level with bilateral neural foraminal narrowing.
- 2 - scan-00006
A small, left paracentral disc herniation is noted at the L5-S1 level.
The lumbar facet joints show slight degenerative changes, more so on the left at the L5-S1 level and bilaterally at the L4-L5 and L2-L3 levels.
The lumbar vertebral bodies and the intervertebral discs reveal normal signal intensity. The rest of the facet joints and 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 L2-L3
19.0 mm at L3-L4
1. Post-operative status.
2. Slight forward subluxation of the L4 over the L5 vertebra.
3. A large right paracentral and postero-lateral disc extrusion at the L4-L5 level with superior migration of the disc which is seen to lie in the right lateral recess of the L4 vertebra impinging the traversing right L4 nerve root. There is suggestion of inflammation of the right L5 nerve root.
4. Small left paracentral posterior disc herniation at the L5-S1 level.
- 3 - scan-00006
5. A posterior disc bulge with peridiscal osteophyte at the L2-L3 level with bilateral neural foraminal narrowing.
6. Slight facetal arthropathy in the lumbar region as described.
As compared to the previous MRI dated 00.00.00 (scan no.0000), the patient is now status post-operative. A fairly large right paracentral and postero-lateral disc herniation is noted at the L4-L5 level. The sequestered disc fragment identified previously is not identified on the present study.