Date : 00.00.00
Name of the Patient : Abc XyzIdris Aslmn / M / 52 yrs.
Referred by : Dr. Abc Xyzsari.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE with paresthesias since 2 1/2 months.
H/O spinal surgery 18 years ago (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.
There are post-operative changes in the posterior soft tissues at the L5 level with hemilaminectomy of L4 on the right side. Anterior fusion of the L4 and L5 vertebral bodies is noted with presence of a bone graft and reduction in the height of the L4-L5 intervertebral disc.
There is loss of normal lumbar lordosis with slight forward translation of the L3 over L4 vertebra and retrolisthesis of the L5 over the S1 vertebral body with loss of water content of the lumbar intervertebral discs.
A large posterior and bilateral far lateral disc herniation is seen at the L3-L4 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. There is superior migration of the disc posterior to the L3 vertebra with indentation upon the foraminal portion of the L3 nerve roots is seen. The L3-L4 facet joint on the right side shows hypertrophic degenerative change. Large anterior disc herniation with peridiscal osteophytes is also noted at this level.
- 2 - Scan-00007
A pseudo-posterior and right far lateral disc herniation is seen at the L5-S1 level with anterior indentaion of the thecal sac and right neural foraminal narrowing. There is inferior migration of the disc. Mild indentation upon the extraforaminal portion of the right L5 nerve root and posterior displacement of the right S1 nerve root is seen. Mild flavum hypertrophy is also noted at this level.
Hypertrophy of the facet joints is also seen at the L4-L5 and L5-S1 levels.
Type II degenerative changes are noted in the L4 vertebral body adjacent to the L4-L5 intervertebral disc and in the antero-superior portion of the L4.
There is clumping of the L4 nerve roots, centrally posterior to L4 vertebra.
The rest of the lumbar vertebral bodies 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 S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
16.0 mm at L1-L2
16.0 mm at L2-L3
9.0 mm at L3-L4
15.0 mm at L4-L5
12.0 mm at L5-S1.
- 3 - Scan-00007
The MRI features are suggestive of :
1. Post-operative status.
2. A large posterior and bilateral far lateral disc herniation at the L3-L4 level with superior migration of the disc with hypertrophic facetal arthropathy on the right side at this level with canal stenosis.
3. A pseudo-posterior and right far lateral disc herniation at the L5-S1 level with posterior displacement of the right S1 nerve root.