/8 Date : 00.00.00
Name of the Patient : Abc XyzNerulmn / M / 70 yrs.
Referred by : Dr. Abc Xyzvade.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with tingling since 2-3 months.
H/O ? spinal surgery in May 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.
The L5 vertebra appears to be sacralized and the L1 vertebra is as marked on the film.
There is laminectomy of the L3, L4 and L5 vertebrae with post-operative changes in the posterior soft tissues.
There is Grade II spondylolisthesis of the L3 vertebra over the L4 vertebra. There is spondylolysis of the L3 vertebra bilaterally.
There is a pseudo-posterior disc bulge with peridiscal osteophytes indenting the thecal sac and narrowing both neural foramina at the L3-L4 level. An anterior disc herniation is noted at this level. Type I/II/III degenerative changes are seen within the L3 and L4 vertebral bodies adjacent to the L3-L4 intervertebral disc.
The L3-L4 facet joints show hypertrophic degenerative changes with severe canal stenosis. Bilateral far lateral (extraforaminal) disc herniations are seen at this level. There is impingement of the foraminal portion of both the exiting L3 nerve roots at this level.
Hypointense areas on the T1 Weighted images which turn hyperintense on the T2 Weighted images are seen within the anterior epidural space at the L3-L4 and L4 levels. This may represent scar tissue.
The intrathecal nerve roots over the L3 to S1 vertebral levels are irregular and clumped with some of them plastered to the periphery of the thecal sac.
The L1-L2, L2-L3 and L4-L5 facet joints show hypertrophic degenerative changes.
There is a postero-central disc herniation at the L4-L5 level.
The lumbar intervertebral discs show loss of water content.
The rest of the lumbar vertebral bodies reveal normal signal intensity. 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 :
14.0 mm at L1-L2
15.0 mm at L2-L3
10.0 mm at L3-L4
14.0 mm at L4-L5
13.0 mm at L5-S1.
- 3 - Scan-00007/8
The MRI features are suggestive of :
1. Post-operative status.
2. Grade II spondylolisthesis of the L3 vertebra over the L4 vertebra with spondylolysis of the L3 vertebra bilaterally.
3. Scar tissue within the anterior epidural space at the L3-L4 and L4 levels.
4. Severe hypertrophic facetal arthropathy with canal stenosis and impingement of the foraminal portion of both the exiting L3 nerve roots at the L3-L4 level.
5. A postero-central disc herniation at the L4-L5 level.
6. Hypertrophic facetal arthropathy at the L1-L2, L2-L3 and L4-L5 levels.
7. A pseudo-posterior disc bulge with peridiscal osteophytes at the L3-L4 level.
8. Arachnoiditis over the L3 to the S1 levels.