sb/ke/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzahim Blmn / M / 72 yrs.
Referred by : Dr. Abc Xyzonawalla.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with paresthesias since 0000.
H/O backache radiating to BLE since 0000 for which patient was operated twice (1st in 0000 and 2nd in 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 reduction in height of the L4-L5 disc and loss of water content of the lumbar intervertebral discs.

There is evidence of laminectomy at the L4 and L5 levels with L4-L5 discectomy and post-operative changes in the soft tissues in the posterior lumbar region at these levels.

There is minimal forward translation of the L4 over the L5 vertebra.

There is a postero-central and right paracentral extruded disc at the L4-L5 level with superior migration of the disc fragment along the posterior margin of the L4 vertebral body. Resultant probable indentation on the exiting right L4 nerve root is noted. There is also hypertrophy of the right facet joint at the L4-L5 level with right lateral recess stenosis. Probable scar tissue is also noted in the right lateral recess of L5.


A small left postero-lateral and left far lateral disc bulge is noted at the L3-L4 level.

The intrathecal nerve roots at the L3-L4 and L4 vertebral levels appear clumped suggesting arachnoiditis.

The lumbar vertebral bodies reveal normal signal intensity. The facet joints at the L5-S1 level also appears slightly hypertrophied. 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 :

17.0 mm at L1-L2
17.0 mm at L2-L3
17.0 mm at L3-L4
16.0 mm at L5-S1.

IMPRESSION :

1. Post-operative status.

2. A postero-central and right paracentral extruded disc at the L4-L5 level with superior migration of the disc fragment indenting the exiting right L4 nerve root.

3. Hypertrophy of the right facet joint at the L4-L5 level with right lateral recess stenosis. Probable scar tissue is also noted in the right lateral recess of L5.

4. A small left postero-lateral and left far lateral disc bulge at the L3-L4 level.

5. Clumped intrathecal nerve roots at the L3-L4 and L4 vertebral levels suggest arachnoiditis.