Date : 00.00.00
Name of the Patient : Abc Xyz Shlmn / M / 57 yrs.
Referred by : Dr. Abc Xyzapadia.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with tingling since February 0000.
H/O L4-L5 laminectomy in April 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 laminectomy at L4 and L5 vertebral levels with post-operative changes in the soft tissues in the posterior lumbar region at these levels.
There is loss of water content of the L4-L5 and L5-S1 intervertebral discs which appear reduced in height.
Slight retroplacement of the L5 over the S1 and the L4 over the L5 vertebrae is noted.
There is seen a postero-central and right paracentral disc herniation with peridiscal osteophytes at the L4-L5 level with indentation on the traversing L5 nerve roots bilaterally more on the right side. The thecal sac is slightly retroplaced at this level due to the previous laminectomy. Scar tissue is noted along the posterior margin of the thecal sac at this level.
A small postero-central protruded disc with peridiscal osteophytes is noted at the L5-S1 level.
Anterior disc herniations with anterior peridiscal osteophytes are noted at L4-L5 and L5-S1 levels.
The facet joints at the L4-L5, L3-L4 and L2-L3 levels appear slightly hypertrophied.
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 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
16.0 mm at L1-L2
15.0 mm at L2-L3
14.0 mm at L3-L4
1. Post-operative status.
2. Slight retroplacement of the L5 over the S1 and the L4 over the L5 vertebrae.
3. A postero-central and right paracentral disc herniation with peridiscal osteophytes at the L4-L5 level with indentation on the traversing L5 nerve roots bilaterally more on the right side.
4. Slight facetal hypertrophy at the L4-L5, L3-L4 and L2-L3 levels.
As compared to the previous MRI dated 00.00.00 (Study No.00008), there is reduction in the size of the disc fragment at the L4-L5 level. The patient is now status post-operative.