Date : 00.00.00
Name of the Patient : Abc Xyz Chlmn / F / 45 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE since 10 days.
H/O lumbar laminectomy (L4-L5 level) 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 are post-operative changes in the posterior soft tissues at the L4 and L5 levels with laminectomy of the L4 vertebra. There is probable discectomy at the L4-L5 level.
A right postero-lateral disc herniation is seen at the L2-L3 level with indentation upon the foraminal and extraforaminal portion of the right L2 nerve root. There is slight superior migration of the disc.
Small posterior disc bulges are noted at the L3-L4 and the L5-S1 levels.
Small posterior peridiscal osteophyte is noted at the L4-L5 level.
Anterior disc herniation is seen at the L3-L4 level.
The L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content.
The L5-S1 facet joint on the left side and the L3-L4 and L4-L5 facet joints bilaterally show degenerative changes.
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 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 :
17.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
11.0 mm at L5-S1.
The MRI features are suggestive of :
1. Post-operative status.
2. A right postero-lateral disc herniation at the L2-L3 level with indentation upon the foraminal and extraforaminal portion of the right L2 nerve root.
3. Small posterior disc bulges at the L3-L4 and L5-S1 levels.
4. Small posterior peridiscal osteophyte at the L4-L5 level.
5. Facetal arthropathy at the L5-S1 level on the left side and at the L3-L4 and L4-L5 levels bilaterally.