Date : 00.00.0000Name of the Patient : Abc Xyztra T. Mellmn / M / 52 yrs. Referred by : Dr. Abc Xyzhtekar. Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to LLE with paresthesias. H/O laminectomy done at L4/L5 levels in 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.OBSERVATION :
The L4-L5 and L5-S1 intervertebral discs show loss of water content. There are post-operative changes in the posterior soft tissues at the L4 and L5 levels with laminectomy of the L4 and L5 vertebrae and partial laminectomy of the S1 vertebra.
There is minimal forward translation of the L4 over the L5 vertebra, with break in the pars interarticularis of L4, bilaterally (scans 103.1, 2, 102.7).
A posterior disc herniation with posterior peridiscal osteophytes is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. There is impingement of the left L4 nerve root in the left neural foramen at the L4-L5 level (scan 103.1). The L4-L5 facet joints bilaterally (more on the right side) show degenerative changes.
A postero-central disc herniation with peridiscal osteophytes is noted at the L5-S1 level. A small posterior disc bulge is identified at the L3-L4 level. The intrathecal nerve roots at the L4 and L5 levels appear thick and clumped suggestive of Group I arachnoiditis. Type I and II degenerative changes are noted in the L5 vertebral body adjacent to the L4-L5 disc.
The rest of 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.Fat is noted in the filum terminale over the L4 and L5 levels. The conus medullaris terminates at the L2 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 :18.0 mm at L1-L218.0 mm at L2-L317.0 mm at L3-L4IMPRESSION :1. Post-operative status.
2. Minimal forward translation of the L4 over the L5 vertebra with a break in the pars interarticularis of L4, bilaterally.
- 3 - Scan-00002
3. A posterior disc herniation with peridiscal osteophytes at the L4-L5 level with bilateral neural foraminal narrowing and impingement of the left L4 nerve root in the left neural foramen at the L4-L5 level.
4. A postero-central disc herniation with peridiscal osteophytes at the L5-S1 level. 5. Group I arachnoiditis at the L4 and L5 levels.
As compared to the previous MRI dated 00.00.0000 (study no:00008) there is minimal forward translation of the L4 over the L5 vertebra and impingement of the left L4 nerve root in the left neural foramen at the L4-L5 level.