Name of the Patient : Abc Xyz Slmn / M / 22 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE.
H/O laminectomy of L4 and L5 with discoidectomy of L4-L5 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 is loss of water content of the L3-L4, L4-L5 and L5-S1 intervertebral discs.
There is evidence of laminectomy of the L4 and L5 vertebrae with post-operative changes in the soft tissues in the posterior lumbar region at these levels. H/O discoidectomy of the L4-L5 disc is noted.
There is still seen a small posterior and left far lateral disc bulge with peridiscal osteophyte at the L4-L5 level with slight left neural foraminal narrowing.
Small postero-central disc herniations with peridiscal osteophytes are noted at the L3-L4 and L5-S1 levels.
Slight facetal hypertrophy is noted at the L3-L4, L4-L5 and L5-S1 levels.
The lumbar vertebral bodies and the remaining intervertebral discs 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 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 :
19.0 mm at L1-L2
18.0 mm at L2-L3
16.0 mm at L3-L4
1. Post-operative status.
2. A small posterior and left far lateral disc bulge with peridiscal osteophyte at the L4-L5 level with slight left neural foraminal narrowing.
3. Small postero-central disc herniations with peridiscal osteophytes at the L3-L4 and L5-S1 levels.
4. Slight facetal hypertrophy at the L3-L4, L4-L5 and L5-S1 levels.
As compared to the previous MRI dated 00.00.00 (study no:0000) patient is now status post-operative. There is slight decrease in the degree of the posterior disc protrusion at the L4-L5 level. The left far lateral component of the L4-L5 disc is largely unchanged.