Name of the Patient : Abc XyzZlmn / M / 47 yrs.
Referred by : Dr. Abc Xyzgtap.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE with paresthesias.
H/O ? spinal surgery at L4-L5 level 1 year ago (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 a suspicious fenestration defect in the right lamina of L5 (scans 104.4,5).
There is a large right postero-lateral disc herniation with peridiscal osteophytes at the L5-S1 level indenting the right antero-lateral aspect of the thecal sac and right neural foraminal narrowing. Inferior migration of the disc is seen impinging the traversing right S1 nerve root. The facet joints at this level appears hypertrophied.
A large left far lateral disc herniation is seen at the L5-S1 level with indentation upon the extraforaminal portion of the left L5 nerve root.
Bilateral postero-lateral disc herniations with peridiscal osteophytes are noted at the L4-L5 level with bilateral neural foraminal narrowing. The L4-L5 facet joints show hypertrophic degenerative changes.
The L4-L5 and L5-S1 intervertebral discs show loss of water content. The L5-S1 intervertebral disc is reduced in height.
Type I/II degenerative changes are noted in the L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral disc and Type II degenerative change is seen in the L4 vertebral body, superiorly.
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
17.0 mm at L2-L3
16.0 mm at L3-L4
15.0 mm at L4-L5
15.0 mm at L5-S1.
1. A large right postero-lateral disc herniation with peridiscal osteophytes at the L5-S1 level with inferior migration of the disc impinging the traversing right S1 nerve root and facetal hypertrophy at this level.
2. A large left far lateral disc herniation with peridiscal osteophytes at the L5-S1 level with indentation upon the extraforaminal portion of the left L5 nerve root.
- 3 - Scan-00003
3. Bilateral postero-lateral disc herniations at the L4-L5 level with hypertrophic facetal arthropathy.
4. The patient is status post-operative (details not available).
No previous investigations were available for comparison.