Date : 00.00.00
Name of the Patient : Abc Xyz Julmn / F / 48 yrs.
Referred by : Dr. Abc Xyzcha.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE since 1 year.
H/O spine surgery 15 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.
There is loss of water content of the L4-L5 and L5-S1 intervertebral discs.
There is evidence of a hemilaminectomy on the left side at the L4 and L5 vertebral levels with post-operative changes in the soft tissues in the posterior lumbar region at these levels. The thecal sac is seen to be bulging outside the spinal canal in the region of the operative site.
There is an intermediate signal on the T1 Weighted images along the left antero-lateral and lateral margins of the thecal sac at the L5 vertebral level. This lesion appears hyperintense of the T2 Weighted images and most likely represents scar tissue. Encasement of the traversing left L5 nerve root is noted.
A posterior and left postero-lateral disc bulge is noted at the L4-L5 level. Slight facetal hypertrophy on the right side is noted at this level.
Small posterior disc bulges are noted at the L3-L4 and L5-S1 levels with slight facetal hypertrophy at the L5-S1 level.
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 :
17.0 mm at L1-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
12.0 mm at L5-S1.
Incidentally noted is a mild right sided hydronephrosis which needs to be further evaluated.
Screening images of the cervical spine reveal a fairly large postero-central and right postero-lateral disc herniation with peridiscal osteophytes at the C6-C7 level and smaller, postero-central protruded discs with peridiscal osteophytes at the C3-C4 and C4-C5 levels.
Screening, T2 Weighted sagittal images of the dorsal spine do not reveal any significant feature of note.
- 3 - Scan-00000
1. Post-operative status.
2. Scar tissue along the left antero-lateral and lateral margins of the thecal sac at the L5 vertebral level with encasement of the traversing left L5 nerve root.
2. A posterior and left postero-lateral disc bulge at the L4-L5 level with slight facetal hypertrophy on the right side at this level.
3. Small posterior disc bulges at the L3-L4 and L5-S1 levels with slight facetal hypertrophy at the L5-S1 level.
4. A fairly large postero-central and right postero-lateral disc herniation with peridiscal osteophytes at the C6-C7 level and smaller, postero-central protruded discs with peridiscal osteophytes at the C3-C4 and C4-C5 levels.
If clinically indicated, a dedicated study of the cervical spine would be worthwhile.