Date : 00.00.00
Name of the Patient : Abc Xyzant R. Mhlmn / M / 50 yrs.
Referred by : Dr. Abc Xyzvade.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
Alleged H/O being knocked by a taxi 1 week back with backache radiating to the RLE with paresthesias since then.
Past H/O lumbar spine surgery 11 years ago. No details 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 is loss of water content of the L4-L5 and L5-S1 intervertebral discs.
There is evidence of laminectomy of the L4 and L5 vertebrae with post-operative changes in the soft tissues in the posterior lumbar region at these levels.
A small postero-central protruded disc is noted at the L5-S1 level.
A fairly large, postero-central and right paracentral extruded disc is noted at the L4-L5 level with thecal sac compression. Slight inferior migration of the disc fragment is noted indenting the traversing right L5 nerve root.
The intrathecal nerve roots at the L4-L5, L5 and S1 levels appear clumped, centrally and to the thecal sac peripherally, suggesting Group I and Group II arachnoiditis.
Slight facetal hypertrophy is noted at the L4-L5 and L5-S1 levels.
Type II degenerative marrow changes are noted adjacent to the L4-L5 intervertebral disc.
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 L1 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 :
15.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
8.0 mm at L4-L5
11.0 mm at L5-S1.
1. Post-operative status.
2. A small postero-central protruded disc at the L5-S1 level.
3. A fairly large, postero-central and right paracentral extruded disc at the L4-L5 level with slight inferior migration of the disc fragment indenting the traversing right L5 nerve root.
4. Group I and Group II arachnoiditis at the L4-L5, L5 and S1 levels.
5. Slight facetal hypertrophy at the L4-L5 and L5-S1 levels.