Date : 00.00.00
Name of the Patient : Abc XyzBamulmn / M / 50 yrs.
Referred by : Dr. Abc Xyz Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias.
H/O L3-L4-L5 laminectomy done 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 is evidence of L3-L4-L5 laminectomy. There are post-operative changes in the posterior soft tissues over the L3 to S1 levels. Mild retroplacement of the L3 over the L4 vertebral bodies is noted.
A posterior and a right postero-lateral disc herniation is seen at the L3-L4 level with antero-lateral indentation of the thecal sac. A portion of the disc is seen to migrate inferiorly in the right lateral recess of the L4 vertebral body with impingement of the right L4 nerve root. The L3-L4 disc shows loss of water content.
A right postero-lateral disc bulge is seen at the L2-L3 level with right neural foraminal narrowing.
Small postero-central protruded disc is noted at the L1-L2 level.
Anterior disc herniation is seen at the L2-L3 level with Type I degenerative marrow changes in the L2 and L3 vertebral bodies.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The intrathecal nerve roots appear unremarkable.
The conus medullaris terminates at the D12-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 :
13.0 mm at L1-L2
13.0 mm at L2-L3
14.0 mm at L3-L4
16.0 mm at L4-L5
16.0 mm at L5-S1.
A probable left cortical renal cyst is noted.
1. Post-operative status.
2. A posterior and a right postero-lateral disc herniation at the L3-L4 level with a portion of the disc seen to migrate inferiorly in the right lateral recess of the L4 vertebral body with impingement of the right L4 nerve root.
3. A right postero-lateral disc bulge at the L2-L3 level.
4. Small postero-central protruded disc at the L1-L2 level.