Date : 00.00.00
Name of the Patient : Abc Xyz Nlmn / F / 42 yrs.
Referred by : Dr. Abc Xyzwhale.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias since 5-6 years.
H/O evening fever since 1-2 years.
H/O L5 laminectomy with discectomy of L5-S1 in September 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 L5-S1 intervertebral disc shows loss of water content.
There are post-operative changes in the posterior soft tissues at the L5 and S1 levels with laminectomy of the L5 vertebra.
A postero-central disc herniation is seen at the L5-S1 level with anterior indentation of the thecal sac and the S1 nerve roots bilaterally.
A posterior and a left postero-lateral disc herniation is noted at the L4-L5 level with anterior indentation of the thecal sac and left neural foraminal narrowing. The L4-L5 facet joint on the left shows mild degenerative change.
A small posterior disc bulge is seen at the L3-L4 level. This intervertebral disc shows slight loss of water content.
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 L1 level and the thecal sac terminates at the S1-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-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
12.0 mm at L4-L5
13.0 mm at L5-S1.
1. Post-operative status.
2. A postero-central disc herniation at the L5-S1 level with indentation upon the S1 nerve roots.
3. A posterior and a left postero-lateral disc herniation at the L4-L5 level with tight lumbar canal at this level.