Date : 00.00.00
Name of the Patient : Abc Xyzohd. Qurlmn / M / 50 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE with paresthesias since 20 years.
H/O spinal surgery 15-20 years ago (Details not available).
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.
FEW IMAGES SHOW PATIENT MOTION.
There appears to be sacralization of the L5 vertebra and the L1 vertebra is as marked on the film.
There is laminectomy of the L3 and L4 vertebrae and partial laminectomy of the L2 and L5 vertebrae with post-operative changes within the posterior soft tissues at these levels.
A postero-central disc herniation, more to the left of the midline, with peridiscal osteophytes is seen to indent the thecal sac at the L4-L5 level.
There are bilateral postero-lateral (foraminal) disc herniations with peridiscal osteophytes narrowing both neural foramina at the L3-L4 level.
A posterior disc bulge with peridiscal osteophytes is seen to indent the thecal sac at the L2-L3 level. Bilateral far lateral (extraforaminal) disc bulges are noted at the L2-L3, L3-L4 and L4-L5 levels.
The L2-L3, L3-L4 and L4-L5 facet joints show degenerative changes. Mild facetal hypertrophy is noted at the L1-L2 level.
The intrathecal nerve roots at the L3 and L4 levels are irregularly defined and clumped and this may suggest Group I arachnoiditis. The nerve roots at the L5 level are plastered to the periphery of the thecal sac and this may suggest Group II arachnoiditis.
The lumbar intervertebral discs show loss of water content. A hyperintense area on the T2 Weighted images within the L3-L4 intervertebral disc on the left side is noted (? calcified disc).
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 dorsal spine was screened with 5 mm thick T2 Weighted sagittal images and shows mild facetal hypertrophy at the D9-D10 level.
The MRI features are suggestive of :
1. Post-operative status.
2. Sacralization of the L5 vertebra.
3. A postero-central disc herniation, more to the left of the midline, with peridiscal osteophytes at the L4-L5 level.
4. Bilateral postero-lateral (foraminal) disc herniations with peridiscal osteophytes at the L3-L4 level.
- 3 - Scan-00008
5. Facetal arthropathy at the L2-L3, L3-L4 and L4-L5 levels.
6. Arachnoiditis over the L3 to the L5 levels.