ke/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc XyzJelmn / F / 38 yrs.
Referred by : Dr. Abc Xyzagwati.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the LLE since 2 months.
H/O L4-L5 hemilaminectomy with discectomy done in May 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 :

The lumbar intervertebral discs except for the L1-L2 show loss of water content.

There are post-operative changes in the posterior soft tissues at the L5 level. A partial laminotomy with facetectomy at the L5 level on the right side is noted.
Small posterior peridiscal osteophytes are noted at the L4-L5 level. This disc is reduced in height. There are hypertropic changes in the facet joints at the L4-L5 level on the left side.

There is a small posterior disc herniation at the L3-L4 level with anterior indentation of the thecal sac.

Type II degenerative changes are noted in the L4 and L5 vertberal bodies adjacent to the L4-L5 intervertebral disc.

Anterior peridiscal osteophytes are seen in the dorsal region.


The rest of the lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints and 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 :

18.0 mm at L1-L2
18.0 mm at L2-L3
17.0 mm at L3-L4
15.0 mm at L4-L5
13.0 mm at L5-S1.

IMPRESSION :

1. Post-operative status.

2. Hypertrophy of the facet joints at the L4-L5 level on the left side with small posterior peridiscal osteophytes at this level.

2. A small posterior disc herniation at the L3-L4 level.