Date : 00.00.00

Name of the Patient : Abc Xyzn N. Ragoowalmn / M / 47 yrs.
Referred by : Dr. Abc Xyz. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

H/O laminectomy with discoidectomy at the L4-L5 level on 00.00.00.
C/O backache radiating to the RLE with paresthesias since 2 1/2 months.

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.

FEW IMAGES SHOW PATIENT MOTION.

OBSERVATION :

There is evidence of laminectomy of the L5 and S1 vertebrae with post-operative changes
within the posterior soft tissues over these levels.

Areas of hypointensity on the T1 Weighted images are seen to involve the L4 and L5 vertebral bodies, L5 pedicles and the L4-L5 intervertebral disc. These turn hyperintense on the T2 Weighted images. There is erosion of the cortical endplates adjacent to the L4-L5 intervertebral disc.

There is extension of the pathologic process into the anterior epidural space over the L4 to S1 vertebral levels with encasement of the nerve roots. Also seen is extension into the pre and paravertebral soft tissues at the L4 and L5 vertebral levels and into the L4-L5 neural foramina.

Bilateral postero-lateral (foraminal) disc herniations are seen to narrow the neural foramina at the L3-L4 level. A right far lateral (extraforaminal) disc herniation is seen to indent the extraforaminal portion of the exiting right L3 nerve root at this level.
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The L3-L4, L4-L5 and L5-S1 facet joints show hypertrophic degenerative changes. The L1-L2 and L2-L3 facet joints show mild degenerative changes.

A posterior disc bulge is seen at the L5-S1 level.

The L3-L4 and L5-S1 intervertebral discs show loss of water content.

IMPRESSION :

The MRI features are suggestive of :

1. Areas of altered signal intensity involving the L4 and L5 vertebrae and L4-L5 intervertebral disc which would represent osteitis with discitis with soft tissue extensions as described.

2. Bilateral postero-lateral (foraminal) disc herniations and a right far lateral (extraforaminal) disc herniation at the L3-L4 level.

3. Hypertrophic facetal arthropathy at the L3-L4, L4-L5 and L5-S1 levels.

No previous investigations were available for comparison.


























Date : 00.00.00


Name of the Patient : Abc Xyzn N. Ragoowalmn / M / 47 yrs.
Referred by : Dr. Abc Xyz. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.


As compared to the previous MRI (scan no:0000) dated 00.00.00, the patient is now status post-operative with changes in the spine as described.

The posteriorly extruded disc at the L4-L5 level is now not seen. Osteitis with discitis as described is seen.