Date : 00.00.00
Name of the Patient : Abc XyzMilmn / M / 41 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE since 3 months.
H/O L4 spinectomy, L4-L5 laminectomy and discectomy done 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 evidence of laminectomy of the L4 vertebra and probable partial laminectomy of the L5 vertebra. There is retroplacement of the thecal sac at this level.
There is loss of normal lumbar lordosis. The L1-L2, L4-L5 and L5-S1 intervertebral discs show loss of water content and are reduced in disc height.
There is a large right paracentral disc extrusion at the L4-L5 level causing right ventro-lateral compression upon the thecal sac. A large disc fragment is seen in the right lateral recess of the L5 vertebra with impingement of the traversing right L5 nerve root.
A postero-central disc herniation is seen at the L1-L2 level with small posterior peridiscal osteophytes causing anterior indentation upon the thecal sac.
A small postero-central disc herniation is noted at the L5-S1 level.
Facetal hypertrophy is seen at the L4-L5 and L5-S1 levels. Also seen is mild facetal hypertrophy at the L3-L4 level.
Type II degenerative changes are noted within the L4 and L5 vertebral bodies adjacent to the L4-L5 intervertebral disc.
The remaining lumbar vertebral bodies and the rest of the intervertebral discs reveal normal signal intensity. The remaining 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 :
17.1 mm at L1-L2
17.6 mm at L2-L3
18.1 mm at L3-L4
14.6 mm at L5-S1.
The MRI features are suggestive of :
1. Post-operative status.
2. A large right paracentral extruded disc at the L4-L5 level causing right ventro-lateral compression upon the thecal sac with a large disc fragment seen in the right lateral recess of the L5 vertebra with compression upon the traversing right L5 nerve root.
3. A postero-central disc herniation at the L1-L2 level.