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Name of the Patient : Abc XyzDarlmn / F / 41 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE and paresthesias.
Past H/O lumbar spine surgery. 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 slight retrolisthesis of the L5 over the S1 vertebra and the L4 over the L5 vertebra.

There is evidence of fenestration surgery on the right side at the L4-L5 level with post-operative changes in the soft tissues in the posterior lumbar region at this level. Partial excision of the spinous process of the L4 and L5 vertebrae is also noted.

There is a small posterior disc herniation at the L5-S1 level with facetal hypertrophy at this level.

A posteriorly herniated disc with peridiscal osteophytes is noted at the L4-L5 level with bilateral neural foraminal narrowing and indentation on the traversing L5 nerve roots bilaterally more on the right side. Facetal hypertrophy is also noted at this level.
Scan-00000


A posterior and right postero-lateral disc herniation with peridiscal osteophytes is noted at the L3-L4 level with slight right neural foraminal narrowing.

A small right paracentral disc herniation with peridiscal osteophytes is noted at the L1-L2 level.

The lumbar vertebral bodies show spotty fatty marrow changes. All the intervertebral discs except the L2-L3 disc show loss of water content. The facet joints at the L2-L3 and L3-L4 levels also appear slightly hypertrophied. 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 :

13.0 mm at L1-L2
18.0 mm at L2-L3
13.0 mm at L3-L4
9.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

1. Post-operative status.

2. Slight retrolisthesis of the L5 over the S1 vertebra and the L4 over the L5 vertebra.

3. A small posterior disc herniation at the L5-S1 level with facetal hypertrophy at this level.
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- 3 - Scan-00000


4. A posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level with bilateral neural foraminal narrowing and indentation on the traversing L5 nerve roots bilaterally more on the right side. Facetal hypertrophy is also noted at this level with lateral and central canal stenosis.

5. A posterior and right postero-lateral disc herniation with peridiscal osteophytes at the L3-L4 level.

6. A small right paracentral disc herniation with peridiscal osteophytes at the L1-L2 level.


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