ke/bv/nl/nl
Date : 00.00.00

Name of the Patient : Abclmn / M / 30 yrs.
Referred by : Dr. Abc Xyzagwati.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE since 1 1/2 years.
H/O lumbar laminectomy done in 0000 for similar complaints.

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.

After administration of contrast 5 mm thick T1 Weighted sagittal and axial images were obtained.

OBSERVATION :

There is loss of water content of the lumbar intervertebral discs.

There are post-operative changes in the posterior soft tissues over the L2 to the L5 levels with laminectomy of the L2 and L3 vertebral bodies.

A large, left paracentral disc extrusion is seen at the L4-L5 level with anterior compression of the thecal sac, canal stenosis and left neural foraminal narrowing. An extruded disc portion is seen to migrate inferiorly in the left lateral recess of the L5 vertebral body with resultant impingement of the traversing left L5 nerve root. The L4-L5 facet joints show mild degenerative change.

A postero-central disc herniation is seen at the L5-S1 level with posterior peridiscal osteophytes and anterior indentation of the thecal sac.


Small posterior disc bulges with posterior peridiscal osteophytes are noted at the L1-L2, L2-L3 and L3-L4 levels. There is hypertrophy of the facet joints in the lumbar region.

The intrathecal nerve roots show normal distribution. There is no evidence of arachnoiditis.

After administration of contrast, there is no abnormal area of enhancement within the visualized spinal canal and the meninges.

The lumbar vertebral bodies reveal normal signal intensity. 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 S2 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

14.0 mm at L1-L2
14.0 mm at L2-L3
13.0 mm at L3-L4
8.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

1. Post-operative status.
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2. A large, left paracentral disc extrusion at the L4-L5 level with an extruded disc portion migrating inferiorly in the left lateral recess of the L5 vertebral body with resultant impingement of the traversing left L5 nerve root and canal stenosis.

3. A postero-central disc herniation at the L5-S1 level.

4. Small posterior disc bulges with posterior peridiscal osteophytes at the L1-L2, L2-L3 and L3-L4 levels.