sb/ke/nl/rg.
Name of the Patient : Abc Xyz Bootwlmn / F / 48 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE since 6 days.
H/O lumbar laminectomy at L4-L5 with discoidectomy on 00.00.0000.
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 loss of water content of the L3-L4, L4-L5 and L5-S1 intervertebral discs.
There is evidence of laminectomy at the L5 vertebral level and partial laminectomy at the L4 vertebral level with post-operative changes in the soft tissues in the posterior lumbar region at these levels.
There is a small left postero-lateral disc herniation with peridiscal osteophytes at the L5-S1 level with slight left neural foraminal narrowing. The L5-S1 facet joint on the left side shows hypertrophic degenerative changes.
A right postero-lateral disc herniation with peridiscal osteophytes is noted at the L4-L5 level with right neural foraminal narrowing. Facetal hypertrophy is noted at the L4-L5 level bilaterally.
A left postero-lateral and left far lateral disc herniation is noted at the L3-L4 level with left neural foraminal narrowing and indentation on the extraforaminal segment of the left L3 nerve root.
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The margins of the thecal sac and the epidural fat are not well differentiated at the L4-L5 level, probably due to scar tissue.
A hemangioma with fat content is noted in the L1 and L3 vertebral bodies.
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.
The conus medullaris terminates at the L1-L2 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 :
19.0 mm at L1-L2
18.0 mm at L2-L3
17.0 mm at L3-L4
IMPRESSION :
1. Post-operative status.
2. A small left postero-lateral disc herniation with peridiscal osteophytes at the L5-S1 level.
3. A right postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with right neural foraminal narrowing.
4. A left postero-lateral and left far lateral disc herniation at the L3-L4 level with indentation on the extraforaminal segment of the left L3 nerve root.
4. Facetal hypertrophy at the L4-L5 and L5-S1 levels.
5. Probable scar tissue in the epidural space at the L4-L5 level.
No previous investigations were available for comparison.