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Date : 00.00.00

Name of the Patient : Abc XyzMohammed Slmn / M / 55 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with tingling.
H/O spinal surgery 11 months back. Details not available.

EXAMINATION :

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.

OBSERVATION :

There is evidence of laminectomy at the L4 and L5 vertebral levels with post-operative changes in the soft tissues in the posterior lumbar region at these levels. Probable discoidectomy at the L4-L5 level is also noted. The L4-L5 disc is reduced in height. Slight retroplacement of the L4 over the L5 vertebra is noted.

The L4 and L5 vertebral bodies adjacent to the L4-L5 intervertebral disc appear hypointense on the T1 Weighted images and slightly hyperintense on the T2 Weighted images. These changes may be the sequelae of previous surgery.

A posterior peridiscal osteophyte is noted at the L4-L5 level indenting the dural theca anteriorly and narrowing the neural foramina bilaterally at this level. There is resultant lateral recess stenosis at the L4-L5 level.
Scan-00008


A posteriorly bulging disc with posterior peridiscal osteophyte is noted at the L3-L4 level with bilateral neural foraminal narrowing.

A postero-central disc herniation is noted at the L5-S1 level, with bilateral neural foraminal narrowing.

Facetal hypertrophy is noted at the L3-L4, L4-L5 and L5-S1 levels bilaterally.

The rest of 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.

The conus medullaris terminates at the D12 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
16.0 mm at L2-L3
12.0 mm at L3-L4

IMPRESSION :

1. Post-operative status.

2. Altered signal in the L4 and L5 vertebral bodies adjacent to the L4-L5 intervertebral disc may be the sequelae of previous surgery.
..3/.









- 3 - Scan-00008



3. A posterior peridiscal osteophyte at the L4-L5 level with bilateral neural foraminal narrowing and resultant lateral recess stenosis at the L4-L5 level.

4. A posteriorly bulging disc with posterior peridiscal osteophyte at the L3-L4 level.

5. A postero-central disc herniation at the L5-S1 level.

6. Facetal hypertrophy at the L3-L4, L4-L5 and L5-S1 levels bilaterally.

7. Canal stenosis at the L3-L4 and L4-L5 levels.






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