Date : 00.00.00
Name of the Patient : Abc Xyznnisha lmn / F / 50 yrs.
Referred by : Dr. Abc Xyzdhwa.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias since 0000.
H/O laminectomy at the L5-S1 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.
The lumbar intervertebral discs show loss of water content.
There are post-operative changes in the posterior soft tissues over the L3 to S1 levels with laminectomy of the L4 and L5 vertebrae.
There is a right postero-lateral disc herniation at the L5-S1 level with right neural foraminal narrowing and mild indentation upon the right S1 nerve root and the extraforaminal portion of the right L5 nerve root. A left antero-lateral disc herniation is also noted at this level. The right S1 nerve root appears to be of larger calibre and is ? inflamed, ?? has a baggy nerve root sleeve.
Bilateral far lateral disc herniations are seen at the L4-L5 level with anterior indentation of the thecal sac and neural foraminal narrowing. There is indentation upon the extraforaminal and foraminal portion of the L4 nerve roots bilaterally.
- 2 - Scan-00004
Mild retroplacement of the L3 over the L4 vertebra is noted with a posterior disc herniation at the L3-L4 level with anterior compression upon the thecal sac, bilateral neural foraminal narrowing and a tight canal at this level.
A small posterior disc bulge is noted at the L2-L3 level. Anterior disc herniations are seen at the L2-L3 and L3-L4 levels. The lower lumbar facet joints show mild degenerative changes.
The intrathecal nerve roots appear slightly thick over the L3-L4 to the L5-S1 levels suggestive of Group I arachnoiditis.
The lumbar vertebral bodies 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 S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
16.0 mm at L1-L2
14.0 mm at L2-L3
8.0 mm at L3-L4.
The MRI features are suggestive of :
1. Post-operative status.
- 3 - Scan-00004
2. A right postero-lateral disc herniation at the L5-S1 level with mild indentation upon the right S1 nerve root and the extraforaminal portion of the right L5 nerve root.
3. Bilateral far lateral disc herniations at the L4-L5 level with indentation upon the extraforaminal and foraminal portion of the L4 nerve roots bilaterally.
4. Mild retroplacement of the L3 over the L4 vertebra with a posterior disc herniation at the L3-L4 level and a tight canal at this level.
5. Group I arachnoiditis over the L3-L4 to the L5-S1 levels.