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Name of the Patient : Abc XyzPlmn / M / 69 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain to BLE with numbness since 1 month.
H/O spinal surgery 14 years ago. Details not available.

EXAMINATION :

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.

OBSERVATION :

There is loss of water content of the lumbar intervertebral discs.

There is spondylolysis of the L4 vertebra on the left (scan 102.2). Slight retroplacement of L1 over the L2 and L2 over the L3 vertebrae is noted.

There is evidence of laminectomy over the L2 to L5 vertebral levels with post-operative changes in the posterior soft tissues over these levels. Probable L4-L5 discectomy is also noted.

Posterior disc bulges with peridiscal osteophytes are noted at the L2-L3 and L4-L5 levels with bilateral neural foraminal narrowing, more at the L2-L3 and L3-L4 levels.

There is a left postero-lateral disc herniation at the L3-L4 level with inferior migration of the disc in the left lateral recess of L4 with impingement of the left L4 nerve root.


Left and right postero-lateral disc bulges are noted at the L1-L2 level.

The facet joints in the lumbar region appear hypertrophied, maximum at the L3-L4 level. Ligamentum flavum hypertrophy is also noted at the L3-L4 level.

The lumbar vertebral bodies reveal spotty fatty marrow changes.

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 :

13.0 mm at L1-L2

IMPRESSION :

1. Post-operative status.

2. Spondylolysis of the L4 vertebra on the left.

3. Posterior disc bulges with peridiscal osteophytes at the L2-L3 and L4-L5 levels with bilateral neural foraminal narrowing, more at the L2-L3 level.

4. A left postero-lateral disc herniation at the L3-L4 level with impingement of the L4 nerve root.
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- 3 - Scan-00008



5. Left and right postero-lateral disc bulges at the L1-L2 level.

6. Facetal hypertrophy in the lumbar region, maximum at the L3-L4 level.

7. Ligamentum flavum hypertrophy at the L3-L4 level.

8. Canal stenosis at the L3-L4 level.
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