Date : 00.00.00
Name of the Patient : Abc XyzB. Katlmn / F / 60 yrs.
Referred by : Dr. Abc Xyzwant.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE with paresthesias since 1 year.
H/O similar complaints in 0000 for which decompressive lumbar laminectomy of L3-L4 was 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 are post-operative changes in the posterior soft tissues over the L2 to L5 vertebral levels with laminectomy of the L2, L3 and L4 vertebral bodies.
There is mild retroplacement of the L3 over the L4 and L4 over the L5 vertebral bodies.
The lumbar intervertebral discs show loss of water content. There is exaggeration of the normal lumbar lordotic curve.
Diffuse posterior disc herniations are seen at the L3-L4 and L4-L5 levels with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. A right far lateral disc herniation is also seen at the L4-L5 level with indentation upon the extraforaminal portion of the right L4 nerve root. The facet joints at these levels show degenerative changes with resultant lateral recess stenosis.
Ligamentum flavum hypertrophy is seen at the L4-L5 level.
Posterior and bilateral far lateral disc bulges with peridiscal osteophytes is noted at the L5-S1 level with anterior indentation of the thecal sac. The L5-S1 facet joints show degenerative changes (right more than left). Ligamentum flavum hypertrophy is seen at the L5-S1 level.
Schmorls nodes are seen in the upper lumbar region with apparent central wedging of the L1, L2 and L3 vertebral bodies. Fatty changes are noted in the lumbar vertebral bodies.
The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The intrathecal nerve roots show normal distribution.
The conus medullaris terminates at the 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 :
15.0 mm at L1-L2
15.0 mm at L5-S1.
The cervico-dorsal spine was screened with 4 mm thick T2 Weighted sagittal images and show posterior disc bulges with peridiscal osteophytes at the C3-C4, C4-C5 and C5-C6 levels.
The MRI features are suggestive of :
1. Post-operative status.
- 3 - Scan-00005
2. Mild retroplacement of the L3 over the L4 and L4 over the L5 vertebral bodies.
3. Diffuse posterior disc herniations at the L3-L4 and L4-L5 levels with facetal arthropathy and resultant lateral recess stenosis with ligamentum flavum hypertrophy at the L4-L5 level.
4. A right far lateral disc herniation at the L4-L5 level with indentation upon the extraforaminal portion of the right L4 nerve root.
5. Posterior and bilateral far lateral disc bulges with peridiscal osteophytes at the L5-S1 level with facetal arthropathy and ligamentum flavum hypertrophy at this level.