Date : 00.00.00
Name of the Patient : Abc Xyzl Vlmn / M / 77 yrs.
Referred by : Dr. Abc Xyzurya.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating the LLE since 0000 with tingling in the LLE since 20 days.
H/O decompressive laminectomy over L1 to L5 was 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 is evidence of laminectomy of the L1 to L5 vertebrae with post-operative changes within the posterior soft tissues over these levels. Also seen is forward listhesis of the L4 over the L5 and retrolisthesis of the L2 over the L3 vertebrae.
Posterior disc herniations are seen to indent the thecal sac and narrow the neural foramina bilaterally with impingement of the exiting L2 and L4 nerve roots at the L2-L3 and L4-L5 levels respectively.
Small posterior disc herniations are seen to indent the thecal sac and narrow the neural foramina bilaterally at the L1-L2 and L3-L4 levels.
Far lateral (extraforaminal) disc herniations are seen bilaterally over the L1-L2 to L4-L5 levels.
The L2-L3, L3-L4 and L4-L5 facet joints show hypertrophic degenerative changes. The L1-L2 facet joints show degenerative changes.
- 2 - scan-00008
The L1-L2 to L4-L5 intervertebral discs show loss of water content. Type I/II degenerative changes are noted within the L2 and L3 vertebral bodies adjacent to the L2-L3 intervertebral disc. Anterior disc herniations with peridiscal osteophytes are seen at the L1-L2 and L2-L3 levels. 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 MRI features are suggestive of :
1. Post-operative status.
2. Posterior disc herniations with impingement of the exiting L2 and L4 nerve roots at the L2-L3 and L4-L5 levels respectively.
3. Small posterior disc herniations at the L1-L2 and L3-L4 levels.
4. Hypertrophic facetal arthropathy at the L2-L3, L3-L4 and L4-L5 levels.
5. Facetal arthropathy at the L1-L2 level.
6. Canal stenosis over the L1-L2 to the L4-L5 levels.
7. Forward listhesis of the L4 over the L5 and retrolisthesis of the L2 over the L3 vertebrae.
8. Bilateral far lateral (extraforaminal) disc herniations over the L1-L2 to the L4-L5 levels.