Date : 00.00.00
Name of the Patient : Abc Xyzi A. Mlmn / F / 50 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
H/O laminectomy of L4-L5 and discoidectomy on 00.00.00 for backache.
Now C/O backache radiating to BLE (left more than right) since 2 years which has increased since 1 month.
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 sacralization of the L5 vertebra and the L3 vertebral body is as marked on the film.
There is evidence of laminectomy of L4 and L5 vertebrae with post-operative changes in the soft tissues in the posterior lumbar region at these levels.
Probable fusion of L4 and L5 vertebrae is noted. The L4-L5 intervertebral disc is not well identified. The rest of the intervertebral discs show loss of water content.
Small posterior disc bulge with peridiscal osteophytes is noted at the L3-L4 level.
Right far lateral disc bulges with peridiscal osteophytes are noted at the L2-L3 and L1-L2 levels.
Slight facetal hypertrophy is noted in the lumbar region.
The L3, L4 and L5 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.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
14.0 mm at L1-L2
18.0 mm at L2-L3
14.0 mm at L3-L4
1. Post-operative status with probable fusion of the L4 and L5 vertebral bodies and non-visualization of the L4-L5 disc.
2. Small posterior disc bulge with peridiscal osteophytes at the L3-L4 level.
3. Right far lateral disc bulges with peridiscal osteophytes at the L2-L3 and L1-L2 levels.
4. Slight facetal hypertrophy in the lumbar region.