Date : 27.l0.99
Name of the Patient : Abc XyzZiaulmn / M / 65 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE since 2 months.
H/O spinal surgery done 40 years back (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.
There appears to be hemilaminectomy on the left side at the L5 vertebral level.
There is slight retroplacement of the L5 over the S1 and of the L3 over the L4 vertebrae.
Posterior disc herniations with peridiscal osteophytes are seen to indent the thecal sac and narrow both neural foramina at the L4-L5 and L5-S1 levels.
Bilateral far lateral (extraforaminal) disc herniations are seen at the L3-L4, L4-L5 and L5-S1 levels.
The L1-L2, L2-L3, L3-L4 and L4-L5 facet joints show hypertrophic degenerative changes.
A posterior disc bulge is noted at the L3-L4 level.
The L5-S1 facet joints show mild degenerative changes.
- 2 - Scan-00005
The intrathecal nerve roots are clumped and irregularly defined over the L4 and L5 levels and would suggest arachnoiditis.
A large lesion which is isointense to CSF is seen in the spinal cord at the S2 level on the right side and would represent a Tarlovs perineurial cyst. A smaller area on the right side is seen at the S1 vertebral level. These are seen to scallop the S1 and S2 vertebral bodies on the right side.
The L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content. The L4-L5 intervertebral disc is decreased in height.
The visualized pre and paravertebral soft tissues are unremarkable.
Areas of fatty replacement of normal marrow are seen in the L4, L5, S1 and S2 vertebral bodies.
The conus medullaris terminates at the D12-L1 level and the thecal sac terminates at the S1-S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
20.0 mm at L1-L2
20.0 mm at L2-L3
12.0 mm at L3-L4
17.1 mm at L4-L5
12.5 mm at L5-S1.
The MRI features are suggestive of :
1. Post-operative status.
- 3 - Scan-00005
2. Posterior disc herniations with peridiscal osteophytes at the L4-L5 and L5-S1 levels.
3. Bilateral far lateral (extraforaminal) disc herniations at the L3-L4, L4-L5 and L5-S1 levels.
4. Hypertrophic facetal arthropathy at the L1-L2, L2-L3, L3-L4 and L4-L5 levels.
5. Tight spinal canal at the L3-L4, L4-L5 and L5-S1 levels.
6. Arachnoiditis over the L4 and L5 levels.