Name of the Patient : Abc Xyz Shilmn / M / 35 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE with paresthesias and right foot drop.
Past H/O spinal surgery on 00.00.0000. 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 loss of normal lumbar lordosis.
There are post-operative changes in the posterior soft tissues over the L3 to S1 vertebral levels with laminectomy of the L4 and L5 vertebrae. A hyperintense signal on the T2 Weighted images along the posterior margin of the thecal sac is noted at the L4 vertebral level, which is slightly hyperintense to CSF on the T1 Weighted images. This may either represent a pseudomeningocele or a post-operative collection/surgicel.
A large posterior disc herniation is seen at the L3-L4 level with anterior compression of the thecal sac and bilateral neural foraminal narrowing. There is facetal hypertrophy at this level, with significant canal stenosis.
Small posterior and right far lateral disc bulges are noted at the L4-L5 and L5-S1 levels with anterior indentation of the thecal sac at the L4-L5 level.
An anterior and posterior disc herniation is noted at the L1-L2 level with anterior indentation of the thecal sac. The L1-L2, L3-L4 and L4-L5 intervertebral discs show loss of water content.
Post-operative tissue is noted in the lateral and posterior epidural space over the operative site.
Facetal hypertrophy is also noted at the L2-L3, L4-L5 and L5-S1 levels.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The intrathecal nerve roots at the L3-L4 and L4-L5 levels are not well identified.
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 :
16.0 mm at L1-L2
13.0 mm at L2-L3
7.0 mm at L3-L4
12.0 mm at L5-S1.
1. Post-operative status.
- 3 - Scan-00004
2. A large posterior disc herniation at the L3-L4 level with facetal hypertrophy and canal stenosis.
3. Small posterior and right far lateral disc bulges at the L4-L5 and L5-S1 levels.
4. Facetal hypertrophy at the L2-L3, L4-L5 and L5-S1 levels.
5. ? pseudomeningocele, ? post-operative collection/surgicel at the operative site.
No previous investigations were available for comparison.