Date : 00.00.00
Name of the Patient : Abc Xyza Mirlmn / F / 53 yrs.Referred by : Dr. Abc Xyzngsarkar.Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :C/O backache radiating to the RLE with paresthesias since 1 year.L4 laminar excision with bilateral intertransverse fusion of L3 and L4 was done for lysis at L4, on 00.00.00.
Good relief for 3 months after surgery. Recurrence of symptoms for the last 3 months with persistent right sided radiculitis.
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 slight reduction in height and loss of water content of the L4-L5 intervertebral disc. There is mild forward translation of the L4 vertebra over the L5 vertebra.
There is evidence of laminectomy at the L4 vertebral level with post-operative changes in the soft tissues in the posterior lumbar region at these levels.
There is seen a posterior and right far lateral disc herniation at the L4-L5 level with bilateral neural foraminal narrowing. Indentation on the extraforaminal segment of the right L4 nerve root is seen.
Break in the pars interarticularis is noted at L4, on the left. Probable partial excision of the inferior articular facet of L4 is noted.
A mild posterior disc bulge is seen at the L5-S1 level.The lumbar articular facets at the L3-L4 and L5-S1 levels are mildly hypertrophic.Areas of hypointensity on all the pulse sequences within the L2 vertebral body may represent marrow inhomogenity. The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable
The conus medullaris terminates at the L1-L2 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 :18.0 mm at L1-L219.0 mm at L2-L320.0 mm at L3-L414.0 mm at L5-S1.
The intrathecal nerve roots appear clumped at the L4-L5 level suggesting arachnoiditis.
- 3 - Scan-00003
1. Post-operative status.
2. Slight forward translation of the L4 over the L5 vertebra with spondylolysis at L4.
3. A posterior and right far lateral disc herniation at the L4-L5 level indenting the extraforaminal portion of the right L4 nerve root. 4. Facetal hypertrophy at the L3-L4 and L5-S1 levels.
As compared to the previous MRI (study no:0000) dated 00.00.00, the patient is now status post-operative. The degree of disc herniation at the L4-L5 level is also unchanged.