Date : 00.00.00
Name of the Patient : Abc Xyz Jalmn / M / 44 yrs.
Referred by : Dr. Abc Xyzrankar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE with paresthesias since 15-20 days.
H/O discectomy in March 0000 and thecal sac decompression on 00.00.00 (exact 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.
The L2-L3 and L3-L4 intervertebral discs show loss of water content.
There are post-operative changes in the posterior soft tissues over the L2 to L5 levels with laminectomy over the L2 and the L3 vertebral body and probable partial laminotomy at the L4 level.
Diffuse posterior disc herniation with posterior peridiscal osteophytes are seen at the L3-L4 level with anterior compression of the thecal sac, bilateral neural foraminal narrowing and canal stenosis. The L3-L4 facet joints show hypertrophic degenerative changes.
A small posterior disc herniation is noted at the L2-L3 level with anterior indentation of the thecal sac.
Small posterior disc bulges are seen at the L4-L5 and L5-S1 levels with posterior peridiscal osteophytes and bilateral neural foraminal narrowing at the L4-L5 level.
- 2 - Scan-00006
The lumbar facet joints show degenerative changes.
The pedicles of the lumbar vertebrae appear congenitally short in their antero-posterior dimensions.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
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 :
14.0 mm at L1-L2
12.0 mm at L4-L5
10.0 mm at L5-S1.
The MRI features are suggestive of :
1. Post-operative status.
2. Diffuse posterior disc herniation with posterior peridiscal osteophyhtes at the L3-L4 level with canal stenosis and hypertrophic facetal arthropathy at this level.
3. A small posterior disc herniation at the L2-L3 level.
4. Congenitally short pedicles and facetal arthropathy in the lumbar region.