ke/sb/rg/nl

Name of the Patient : Abc Xyz N. Arsilmn / M / 75 yrs.
Referred by : Dr. Abc Xyzcha.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE since 3 years.
H/O spinal surgery 10 years ago. Details not available.

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 are post-operative changes in the posterior soft tissues over the L2 to S1 vertebral levels with laminectomy of the L2, L3, L4 and the L5 vertebral bodies. There is scoliosis of the lumbar spine with convexity to the right and reduction in the height of L1-L2, L2-L3, L3-L4 and L4-L5 discs.

There are posterior disc bulges with peridiscal osteophytes at the L1-L2, L2-L3, L3-L4 and L4-L5 levels with anterior indentation of the thecal sac.

There is bilateral neural foraminal narrowing at the L4-L5 level, right more than left with indentation upon the foraminal and extraforaminal portion of the right L4 nerve root.

The L3-L4 facet joint on the right side and the L4-L5 facet joints bilaterally show hypertrophic degenerative changes.
The L1-L2, L2-L3 and L5-S1 facet joints show mild degenerative changes.
..2/.






- 2 - Scan-00009


A small posterior disc bulge is seen at the L5-S1 level.
Anterior disc herniations with peridiscal osteophytes are seen in the dorso-lumbar region. The lumbar intervertebral discs show loss of water content.

Fatty changes are noted in the dorso-lumbar vertebral bodies.

The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12-L1 level and the thecal sac terminates at the S1 level.

IMPRESSION :

Severe degenerative changes of the lumbar spine with,

1. Post-operative status.

2. Scoliosis of the lumbar spine with convexity to the right.

3. Posterior disc bulges with peridiscal osteophytes at the L1-L2, L2-L3, L3-L4 and L4-L5 levels.

4. Bilateral neural foraminal narrowing at the L4-L5 level, right more than left with indentation upon the foraminal and extraforaminal portion of the right L4 nerve root.

5. Hypertrophic facetal arthropathy at the L3-L4 level, on the right and at the L4-L5 level bilaterally and
mild facetal arthropathy at the L1-L2, L2-L3 and L5-S1 levels.