Name of the Patient : Abc Xyzbi lmn / F / 66 yrs.
Referred by : Dr. Abc Xyzq.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE since November 0000.
H/O laminectomy done at L4-L5 level on 00.00.0000.
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 sacralization of the L5 vertebra and the L3 vertebral body is as marked on the film.
There is scoliosis of the lumbar spine with convexity to the left side with resultant clockwise rotation of the lumbar vertebral bodies.
The lumbar intervertebral discs show loss of water content.
Post-operative changes are seen in the posterior soft tissues at the L4 and L5 levels with laminectomy of the L4 and L5 vertebrae.
There is a large right postero-lateral disc herniation at the L4-L5 level with antero-lateral indentation of the thecal sac and right neural foraminal narrowing. There is indentation upon the exiting right L5 nerve root. There is also slight superior migration of the disc. The L3-L4 and L4-L5 facet joints show degenerative changes.
Scar/granulation is seen encircling the thecal sac at the S1 level (scan 104.4) and posterior to the thecal sac at the L4 and L5 levels.
- 2 - Scan-00009
A Schmorls node is seen in the superior aspect of the L2 vertebral body and in the lower dorsal region.
There is clumping of the nerve roots centrally within the thecal sac at the L3 and L4 vertebral levels suggestive of arachnoiditis.
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 D12 level and the thecal sac terminates at the L5 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 L2-L3
15.0 mm at L3-L4
10.0 mm at L5-S1.
The right kidney appears smaller than the left and requires further evaluation with ultrasonography.
The MRI features are suggestive of :
1. Post-operative status.
2. Sacralization of the L5 vertebra.
3. A large right postero-lateral disc herniation indenting the exiting right L5 nerve root at the L4-L5 level with slight superior migration of the disc and facetal arthropathy at this level with clumping of the nerve roots over the L3 and L4 levels.
4. Small right kidney which require further evaluation.