Date : 00.00.00
Name of the Patient : Abc Xyzi Srivardhalmn / F / 50 yrs
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE since 5-6 years.
H/O lumbar spine surgery 2 years back. (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.
The lumbar intervertebral discs except for the L5-S1 disc show loss of water content.
There are post-operative changes in the posterior soft tissues at the L4 and L5 levels with partial laminotomy at the L5 level on the left side.
A diffuse posterior disc herniation with peridiscal osteophytes is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. Mild indentation upon the foraminal and extraforaminal portion of the L4 nerve roots is noted.
A posterior and a left far lateral disc herniation is noted at the L3-L4 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing, left more than right.
Postero-central disc herniations are seen at the L1-L2 and L2-L3 levels and a small posterior disc bulge is seen at the L5-S1 level.
The lumbar facet joints show degenerative changes with hypertrophic facetal arthropathy at the L4-L5 and L5-S1 levels.
The intrathecal nerve roots show normal distribution.
The pedicles of the lower lumbar vertebrae are congenitally short in their antero-posterior dimensions.
The lumbar vertebral bodies reveal spotty fatty marrow changes. 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 :
12.0 mm at L1-L2
14.0 mm at L2-L3
12.0 mm at L3-L4
8.0 mm at L4-L5
8.0 mm at L5-S1.
1. Post-operative status.
2. A diffuse posterior disc herniation with peridiscal osteophytes at the L4-L5 level with mild indentation upon the foraminal and extraforaminal portion of the L4 nerve roots.
3. A posterior and a left far lateral disc herniation at the L3-L4 level with bilateral neural foraminal narrowing, left more than right.
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4. Postero-central disc herniations at the L1-L2 and L2-L3 levels.
5. A small posterior disc bulge at the L5-S1 level.
6. Facetal arthropathy in the lumbar region with hypertrophic facetal arthropathy at the L4-L5 and L5-S1 levels.
7. Congenitally short pedicles of the lower lumbar vertebrae in their antero-posterior dimensions.