Date : 00.00.00
Name of the Patient : Abc XyzPlmn / M / 38 yrs.
Referred by : Dr. Abc Xyzane.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O radicular pain in the RLE since 2 months.
H/O laminectomy with discectomy at L4 and L5 levels on 00.00.00.
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 sacralization of the L5 vertebra and the L2 vertebral body is as marked on the film. Mild retrolisthesis of the L4 over the L5 vertebra is noted.
There is loss of normal lumbar lordosis with reduction in height and loss of water of content of the L2-L3 and L4-L5 intervertebral discs.
There is evidence of laminectomy at the L4 and L5 vertebral levels with probable discectomy at the L4-L5 level and post-operative changes in the soft tissues in the posterior lumbar region at these levels.
There is a posteriorly bulging disc with peridiscal osteophytes at the L4-L5 level with bilateral neural foraminal narrowng. Inferior migration of the disc fragment is noted, centrally and more to the right of the midline. Probable indentation of right L5 nerve root is noted. The facet joints at the L4-L5 level appear hypertrophied. The intrathecal nerve roots at the L4-L5 and L5 levels appears plastered to the thecal sac suggesting Group II arachnoiditis.
Small posterior disc bulges are noted at the L2-L3 and L3-L4 levels with facetal hypertrophy at the L3-L4 level.
Type II degenerative marrow changes are seen adjacent to the L4-L5 and L5-S1 intervertebral discs.
The rest of 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 D12 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
17.0 mm at L2-L3
15.0 mm at L3-L4.
1. Post-operative status.
2. Sacralization of the L5 vertebra and the L2 vertebral body is as marked on the film.
3. A posteriorly bulging disc with peridiscal osteophytes at the L4-L5 level with inferior migration of the disc fragment, centrally and more to the right of the midline, probably indenting the right L5 nerve root.
4. Facetal hypertrophy at the L3-L4 and L4-L5 levels.
5. Group II arachnoiditis at the L4-L5 and L5 levels.