Name of the Patient : Abc Xyzd B. Bharlmn / F / 75 yrs.
Referred by : Dr. Abc Xyznkhla.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE (left more than right) with paresthesias.
Past H/O lumbar laminectomy with wiring at the L3-L4 and L5-S1 levels in 0000 and 0000. (Exact details not available).
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 evidence of laminectomy at the L4, L5 and S1 vertebral levels with post-operative changes in the soft tissues in the posterior lumbar region at these levels. Susceptibility artifacts in the posterior soft tissues is the sequelae of previous wiring.
There is loss of water content of the lumbar intervertebral discs.
Small, left paracentral disc herniations with peridiscal osteophytes are noted at the L3-L4, L4-L5 and L5-S1 levels with minimal indentation on the corresponding traversing nerve roots at these levels.
Hypertrophic facetal arthropathy is noted at the L3-L4, L4-L5 and L5-S1 levels. Mild facetal arthropathy is seen at the L1-L2 and L2-L3 levels.
There is slight increase in the posterior epidural fat at the L4-L5 and L5 levels with minimal indentation on the dural theca, posteriorly at these levels.
The intrathecal nerve roots at the L5 and S1 levels appear clumped, peripherally to the thecal sac, suggesting Group II arachnoiditis.
There appears to be a cortical renal cyst on the right side.
The dorso-lumbar vertebral bodies show spotty fatty marrow changes. The visualized pre and paravertebral soft tissues are unremarkable.
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 :
21.0 mm at L1-L2
21.0 mm at L2-L3
20.0 mm at L3-L4
The posterior epidural fat in the lower dorsal region at about the D9, D10 and D11 levels also appears slightly increased, when compared to normal.
1. Post-operative status.
2. Small, left paracentral disc herniations with peridiscal osteophytes at the L3-L4, L4-L5 and L5-S1 levels with minimal indentation on the corresponding traversing nerve roots at these levels.
- 3 - Scan-00000
3. Hypertrophic facetal arthropathy at the L3-L4, L4-L5 and L5-S1 levels.
4. Slight increase in the posterior epidural fat at the L4-L5 and L5 levels and in the lower dorsal region as described.
5. Group II arachnoiditis of the intrathecal nerve roots at the L5 and S1 vertebral levels.