sb/bv/rg.
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Name of the Patient : Abc Xyzint Sulalmn / F / 60 yrs.
Referred by : Dr. Abc Xyzmani.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE with foot drop and inability to walk.
H/O laminectomy at L2/L3/L4 levels in May 0000.
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 scoliotic deformity of the lumbar spine with
loss of normal lumbar lordosis and loss of water content of all the lumbar intervertebral discs except the L5-S1 disc. The L2-L3 and L4-L5 intervertebral discs are reduced in height with irregularity of the adjacent cortical endplates.
There is lateral subluxation of the L2 over L3 and L4 over L5 vertebrae.
Slight forward translation of L2 over L3 vertebra and retroplacement of L3 over L4 and L4 over L5 vertebrae is noted.
There is evidence of laminectomy over the L1 to L3 vertebral levels with post-operative changes in the soft tissues in the posterior lumbar region over these levels.
A small posterior disc bulge is noted at the L5-S1 level with facetal arthropathy at that level.
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A posteriorly herniated disc with peridiscal osteophyte is noted at the L4-L5 level with bilateral neural foraminal narrowing and impingement of the right L4 nerve root in the right lateral neural foramen at the L4-L5 level. There is hypertrophic facetal arthropathy and ligamentum flavum hypertrophy with resultant severe canal stenosis at this level.
A postero-central disc herniation with peridiscal osteophytes is noted at the L3-L4 level. Facetal and ligamentum flavum hypertrophy is also noted with lateral recess stenosis.
A small posterior disc bulge with peridiscal osteophytes is noted at the L2-L3 level. Facetal hypertrophy is noted at this level with lateral recess stenosis.
A posterior peridiscal osteophyte is noted at the L1-L2 level with hypertrophic facetal arthropathy and ligamentum flavum hypertrophy and resultant canal stenosis.
The L2, L3 and L4 vertebral bodies show 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 S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
11.0 mm at L1-L2
6.0 mm at L4-L5
7.0 mm at L5-S1.
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- 3 - Scan-00002
IMPRESSION :
1. Post-operative status.
2. Scoliotic deformity of the lumbar spine with
vertebral bodies instability as described.
3. A small posterior disc bulge at the L5-S1 level with facetal arthropathy at that level.
4. A posteriorly herniated disc with peridiscal osteophyte at the L4-L5 level with impingement of the right L4 nerve root in the right lateral neural foramen at the L4-L5 level with hypertrophic facetal arthropathy and ligamentum flavum hypertrophy with resultant severe canal stenosis at this level.
5. A postero-central disc herniation with peridiscal osteophytes at the L3-L4 level with facetal and ligamentum flavum hypertrophy and lateral recess
stenosis.
6. A small posterior disc bulge with peridiscal osteophytes at the L2-L3 level with facetal hypertrophy and lateral recess stenosis.
7. A posterior peridiscal osteophyte at the L1-L2 level with hypertrophic facetal arthropathy and ligamentum flavum hypertrophy and resultant canal stenosis.
As compared to the previous MRI dated 00.00.0000, there is no significant change noted.