Name of the Patient : Abc XyzD. D. lmn / F / 64 yrs.
Referred by : Dr. Abc Xyzndi / Dr. Abc Xyzar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE with paresthesias since 2 days.
Past H/O L4-L5 laminectomy and discectomy 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.
There is evidence of laminectomy of the L4 and L5 vertebrae with post-operative changes within the posterior soft tissues at these levels.
A small posterior disc herniation is seen to indent the thecal sac at the L4-L5 level. Also seen is a right far lateral disc herniation at this level. Mild bilateral neural foraminal narrowing is seen at this level.
There is a postero-central disc herniation at the L5-S1 level.
Right postero-lateral and right far lateral disc herniation is noted at the L3-L4 level with right neural foraminal narrowing and indentation upon the exiting right L3 nerve root. A part of the disc is seen to migrate superiorly.
Small left far lateral disc herniation is seen at the L2-L3 level.
A right far lateral disc bulge is noted at the L2-L3 level.
The L3-L4, L4-L5 and L5-S1 facet joints show degenerative changes.
The intrathecal nerve roots at the L3 and L4 levels are displaced and this may suggest arachnoiditis.
The lower lumbar intervertebral discs show loss of water content. The lumbar vertebral bodies show spotty fatty marrow changes.
The remaining 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 :
18.0 mm at L1-L2
16.0 mm at L2-L3
14.0 mm at L3-L4
13.0 mm at L4-L5
11.0 mm at L5-S1.
1. Post-operative status.
2. A small posterior and right far lateral disc herniation at the L4-L5 level.
3. A postero-central disc herniation with right postero-lateral and right far lateral disc herniation at the L3-L4 level.