Date : 00.00.00
Name of the Patient : Abc Xyzdas Slmn / M / 48 yrs.
Referred by : Dr. Abc Xyzrankar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since 3 months.
H/O laminectomy in the lumbar region in 0000.
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 the S1 levels with evidence of partial laminectomy of the L5 and S1 vertebrae.
There is a right postero-lateral and right paracentral disc herniation at the L5-S1 level with posterior peridiscal osteophytes. This disc shows loss of water content. The traversing right S1 nerve root appears a little enlarged and may be inflamed.
A posterior disc bulge is seen at the L4-L5 level.
The L4-L5 and L5-S1 facet joints show degenerative changes.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
- 2 - Scan-00000
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 :
13.0 mm at L1-L2
13.0 mm at L2-L3
17.0 mm at L3-L4
18.0 mm at L4-L5.
The MRI features are suggestive of :
1. Post-operative status.
2. A right postero-lateral and right paracentral disc herniation at the L5-S1 level with posterior peridiscal osteophytes. There is probable inflammation of the traversing right S1 nerve root.
3. A posterior disc bulge at the L4-L5 level.
4. Facetal arthropathy at the L4-L5 and L5-S1 levels.