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What Does This MRI Report Of Musco-skeletal Systems Indicate?
Question: The DICOM files of the MRI are sent through e-mail. The files couldn't be uploaded because of file size limitations.
This query is to a Radiologist expert in reading MRI of the musco-skeletal systems.
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For the consulting radiologist: Please study the lumbar MRI in detail and respond to the following:
Background:
The original diagnosis from the MRI by the radiologist was spinal stenosis because of disc degeneration and facet hypertrophy both at right foramina and also at bilateral later recess encroachment. My GP doctor sent me to physio- therapist in January 2013 who asked me to do therapeutic exercises for discogenic issues. This helped and the original claudication related issues and the pain went away in a short period of time. Then I remained nearly symptom free for two years till November 2015 when I had serious sciatic pain in the buttock and legs – but no claudication on walking. This is not resolving as quickly with intervention from physiotherapist (a new one though). My questions are related to fresh evaluation of the MRI in the context of the prognosis and my current symptoms.
Questions:
From the original MRI, would you confirm lumbar stenosis? Both in the foramina and the lateral recesses of the vertebrae, what are the percentages of encroachment due to disc protrusion and due to osteophyte formation respectively?
What changes in the lumbar anatomy- might have taken place considering the remission of original symptoms three years ago and return of current symptoms. Since symptoms are not resolving quickly this time, does it mean that something has drastically changed?
Were there more serious issues that the radiologist did not see in the MRI?
Thanks
XXXX
This query is to a Radiologist expert in reading MRI of the musco-skeletal systems.
******************************************************************************************
For the consulting radiologist: Please study the lumbar MRI in detail and respond to the following:
Background:
The original diagnosis from the MRI by the radiologist was spinal stenosis because of disc degeneration and facet hypertrophy both at right foramina and also at bilateral later recess encroachment. My GP doctor sent me to physio- therapist in January 2013 who asked me to do therapeutic exercises for discogenic issues. This helped and the original claudication related issues and the pain went away in a short period of time. Then I remained nearly symptom free for two years till November 2015 when I had serious sciatic pain in the buttock and legs – but no claudication on walking. This is not resolving as quickly with intervention from physiotherapist (a new one though). My questions are related to fresh evaluation of the MRI in the context of the prognosis and my current symptoms.
Questions:
From the original MRI, would you confirm lumbar stenosis? Both in the foramina and the lateral recesses of the vertebrae, what are the percentages of encroachment due to disc protrusion and due to osteophyte formation respectively?
What changes in the lumbar anatomy- might have taken place considering the remission of original symptoms three years ago and return of current symptoms. Since symptoms are not resolving quickly this time, does it mean that something has drastically changed?
Were there more serious issues that the radiologist did not see in the MRI?
Thanks
XXXX
Brief Answer:
The MRI scan dated 2012 december is analyzed below
Detailed Answer:
Hi,
Thanks for writing in to us.
I have read through your query in detail.
Please find my observations below.
I have downloaded the MRI images in DICOM which belong to the scan done on 12-12-2012.
There is a disc and osteophyte problem in the L 4 - L 5 that you are aware of. I will try to explain the questions you have asked in the attached picture.
1. Is this disc protrusion?
No this is not disc protrusion where the line points to. It is overlying the ligamentum flavum on right side.
2. This is confusing to me? It appears like bone- but it could be only disc? Can you please explain? Also can you please mark the place of osteopath growth?
This points to nerve roots. The disc and bone interface is in front of this. The osteophyte growth is well seen on the sagittal images. Please refer to anatomy of lumbar vertebrae from any reliable source to know the structures in detail. Sorry but marking on picture is not possible because I can reply to you only in text form.
3. To what extent has the LF thickened
The ligamentum flavum has significantly thickened in your case and is causing lumbar spinal stenosis. It has got a histological grading depending on type of fibers.
4. What is this structure? Why the left side looks different from the right side? Which side looks more normal?
It is the facet joint with the superior articular process anteriorly and inferior articular process posteriorly. There is facet joint degeneration more on left side and that is why it looks different.
Lumbar canal stenosis is confirmed and it is due to the combined effect of disc degeneration and ligamentum flavum hypertrophy. Percentage is difficult to say but the osteophytes are less responsible for symptoms.
The lumbar spine disc and nerve root arrangement is delicate. Slight pressure or stress can bring back symptoms after remission. Often I have seen patients who are completely normal and then suddenly cant even walk a step without pain. It is not that something has drastically changes but I believe that a slight stress on your back might have led to the symptoms. Occasionally, a nerve can get pinched in any other location along its course after coming out of the spine and then also it can cause symptoms which can be significantly increased.
Hope your initial query is answered.
Please feel free to ask more doubts.
Regards,
The MRI scan dated 2012 december is analyzed below
Detailed Answer:
Hi,
Thanks for writing in to us.
I have read through your query in detail.
Please find my observations below.
I have downloaded the MRI images in DICOM which belong to the scan done on 12-12-2012.
There is a disc and osteophyte problem in the L 4 - L 5 that you are aware of. I will try to explain the questions you have asked in the attached picture.
1. Is this disc protrusion?
No this is not disc protrusion where the line points to. It is overlying the ligamentum flavum on right side.
2. This is confusing to me? It appears like bone- but it could be only disc? Can you please explain? Also can you please mark the place of osteopath growth?
This points to nerve roots. The disc and bone interface is in front of this. The osteophyte growth is well seen on the sagittal images. Please refer to anatomy of lumbar vertebrae from any reliable source to know the structures in detail. Sorry but marking on picture is not possible because I can reply to you only in text form.
3. To what extent has the LF thickened
The ligamentum flavum has significantly thickened in your case and is causing lumbar spinal stenosis. It has got a histological grading depending on type of fibers.
4. What is this structure? Why the left side looks different from the right side? Which side looks more normal?
It is the facet joint with the superior articular process anteriorly and inferior articular process posteriorly. There is facet joint degeneration more on left side and that is why it looks different.
Lumbar canal stenosis is confirmed and it is due to the combined effect of disc degeneration and ligamentum flavum hypertrophy. Percentage is difficult to say but the osteophytes are less responsible for symptoms.
The lumbar spine disc and nerve root arrangement is delicate. Slight pressure or stress can bring back symptoms after remission. Often I have seen patients who are completely normal and then suddenly cant even walk a step without pain. It is not that something has drastically changes but I believe that a slight stress on your back might have led to the symptoms. Occasionally, a nerve can get pinched in any other location along its course after coming out of the spine and then also it can cause symptoms which can be significantly increased.
Hope your initial query is answered.
Please feel free to ask more doubts.
Regards,
Above answer was peer-reviewed by :
Dr. Yogesh D
Dear Dr. Chail
Thank you so very much for your very illuminating responses. Attached is another composite image that has 3 embedded numbered questions.
In question #2, i think i have not drawn the circle correctly in the image as i am not able to figure out the facet joints correctly. So this is the general area. May be i have got the Superior Articular process - XXXXXXX and IAPs wrong. Since you are not able to send me the images, you can use X, Y coordinates of your DCOM viewer to point out the structures to me.
I am a non-medical person. They told me I have definite stenosis with bilateral nerve root encroachment and some narrowing of the foramen at L4/5. I do not have symptoms of neurogenic claudication, but only right side sciatic pain in buttock and legs, very severe in the morning as I get up from bed. Is this consistent with the MRI? I have heard that this kind of stenosis do not have good surgical outcomes and surgery is complicated. It would be very helpful if you can throw some light on this aspect
Many thanks again
Thank you so very much for your very illuminating responses. Attached is another composite image that has 3 embedded numbered questions.
In question #2, i think i have not drawn the circle correctly in the image as i am not able to figure out the facet joints correctly. So this is the general area. May be i have got the Superior Articular process - XXXXXXX and IAPs wrong. Since you are not able to send me the images, you can use X, Y coordinates of your DCOM viewer to point out the structures to me.
I am a non-medical person. They told me I have definite stenosis with bilateral nerve root encroachment and some narrowing of the foramen at L4/5. I do not have symptoms of neurogenic claudication, but only right side sciatic pain in buttock and legs, very severe in the morning as I get up from bed. Is this consistent with the MRI? I have heard that this kind of stenosis do not have good surgical outcomes and surgery is complicated. It would be very helpful if you can throw some light on this aspect
Many thanks again
Brief Answer:
Please give list of structures for which you require co ordinates
Detailed Answer:
Dear Sir,
Thanks for writing back with an update and acknowledging my observations.
In the new picture
1. This is the neural foramen region. It is better visualized in image 2/11. The narrowing is a comobined effect of disc degeneration and thickening of ligamentum flavum. The facet joint hypertrophy is seen bilaterally, left more than right and has a small contribution to the pain.
2. The XXXXXXX and IAP are in close approximation with each other. When there is degeneration, the surfaces become rough and some fluid accumulated. In your case this is more on the left side.
3. This is not the disc protrusion but the bone with XXXXXXX and IAP interface facet joint interface.
Since there are many structures which we have discussed about, I request you to please give me a list of structures you wish to know the co ordinates of and I will give the information based on a good reference image from your MRI scan including image number and the sequence.
Early morning low back pain is from pinching of nerve.
Surgery cures back pain in about 20 percent of patients. In 40 percent there is no relief and in another 40 percent there is worsening even after surgery.
Your pain can also be due to pyriformis syndrome. This refers to the pinching of sciatic nerve by pyriformis muscle and resulting pain along the nerve. Please discuss this with your doctor.
Waiting for update from you.
Regards,
Please give list of structures for which you require co ordinates
Detailed Answer:
Dear Sir,
Thanks for writing back with an update and acknowledging my observations.
In the new picture
1. This is the neural foramen region. It is better visualized in image 2/11. The narrowing is a comobined effect of disc degeneration and thickening of ligamentum flavum. The facet joint hypertrophy is seen bilaterally, left more than right and has a small contribution to the pain.
2. The XXXXXXX and IAP are in close approximation with each other. When there is degeneration, the surfaces become rough and some fluid accumulated. In your case this is more on the left side.
3. This is not the disc protrusion but the bone with XXXXXXX and IAP interface facet joint interface.
Since there are many structures which we have discussed about, I request you to please give me a list of structures you wish to know the co ordinates of and I will give the information based on a good reference image from your MRI scan including image number and the sequence.
Early morning low back pain is from pinching of nerve.
Surgery cures back pain in about 20 percent of patients. In 40 percent there is no relief and in another 40 percent there is worsening even after surgery.
Your pain can also be due to pyriformis syndrome. This refers to the pinching of sciatic nerve by pyriformis muscle and resulting pain along the nerve. Please discuss this with your doctor.
Waiting for update from you.
Regards,
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dear Dr. Chail
Thanks for the great responses to my queries.
As u have pointed out the problem with the right foramin is clearer in image 2/3 (image 2 of SAG T1). I would think that my symptoms of sciatica and also occasional paraesthesia in the right leg are more in line with the situation in the right foramin. Do you see any osteophyte from the anterior vertebral body in the foraminal opening in this image. I would appreciate if you please point out to the protruded disc, the LF and any osteophyte in the right foramin giving the coordinates and the image number/ seq. no. (sagittal and axial) that would help me understand my situation a little better.
About surgery, there is something called MILD (minimally invasive lumbar decompression: mildprocedure.com) where they basically debulk the LF from the posterior. Because my canal stenosis is primarily because of LF thickening, i think this may be applicable here. What would be your thoughts on this? Would this do any good to the problem in the foramin?
Thanking your once again
Thanks for the great responses to my queries.
As u have pointed out the problem with the right foramin is clearer in image 2/3 (image 2 of SAG T1). I would think that my symptoms of sciatica and also occasional paraesthesia in the right leg are more in line with the situation in the right foramin. Do you see any osteophyte from the anterior vertebral body in the foraminal opening in this image. I would appreciate if you please point out to the protruded disc, the LF and any osteophyte in the right foramin giving the coordinates and the image number/ seq. no. (sagittal and axial) that would help me understand my situation a little better.
About surgery, there is something called MILD (minimally invasive lumbar decompression: mildprocedure.com) where they basically debulk the LF from the posterior. Because my canal stenosis is primarily because of LF thickening, i think this may be applicable here. What would be your thoughts on this? Would this do any good to the problem in the foramin?
Thanking your once again
Brief Answer:
Please find desired location details of structures below
Detailed Answer:
Dear Sir,
Thanks for writing back with an update.
I do agree that your pain and discomfort is caused by nerve root impingement in the right foramen at level L 4 – L 5 disc level. There is the disc protrusion and ligamentum flavum hypertrophy.
Osteophytic changes in the vertebral body is mild and insignificant when we try to reason the pressure from it on the nerve root and it is not really causing foraminal marrowing.
At level L 4 – L 5 the protruding edge of disc is seen in T2 sagittal image 2/ 11 at co ordinate X 269 Y 361
In T2 axial image 15/ 25 the edge of protruding disc is seen at co ordinates X 227 Y 231
At level L 4 – L 5 the ligamentum flavum on right side is seen in T2 sagittal image 5/ 11 at co ordinate X 285 Y 384 in black
In T2 axial image 15/ 25 the ligamentum flavum on right side is seen at co ordinates X 238 Y 245 in black
At vertebra L 5 the small osteophyte on is seen in T2 sagittal image 6/ 11 at co ordinate X 273 Y 368 in white
Minimally invasive lumbar stenosis is an upcoming surgical technique with the use of tubular retractor system and microscope. Studies have shown that the rate of certain complications is significantly reduced. For instance, blood loss, wound infection, iatrogenic instability, and medical deterioration following lumbar decompression using a tubular retractor system are lower compared to open laminectomy which is quoted in a research study.
In experienced hands, your pain might get significantly reduced by this technique.
Hope your query is answered.
Please do write back if you have any doubts.
Regards,
Please find desired location details of structures below
Detailed Answer:
Dear Sir,
Thanks for writing back with an update.
I do agree that your pain and discomfort is caused by nerve root impingement in the right foramen at level L 4 – L 5 disc level. There is the disc protrusion and ligamentum flavum hypertrophy.
Osteophytic changes in the vertebral body is mild and insignificant when we try to reason the pressure from it on the nerve root and it is not really causing foraminal marrowing.
At level L 4 – L 5 the protruding edge of disc is seen in T2 sagittal image 2/ 11 at co ordinate X 269 Y 361
In T2 axial image 15/ 25 the edge of protruding disc is seen at co ordinates X 227 Y 231
At level L 4 – L 5 the ligamentum flavum on right side is seen in T2 sagittal image 5/ 11 at co ordinate X 285 Y 384 in black
In T2 axial image 15/ 25 the ligamentum flavum on right side is seen at co ordinates X 238 Y 245 in black
At vertebra L 5 the small osteophyte on is seen in T2 sagittal image 6/ 11 at co ordinate X 273 Y 368 in white
Minimally invasive lumbar stenosis is an upcoming surgical technique with the use of tubular retractor system and microscope. Studies have shown that the rate of certain complications is significantly reduced. For instance, blood loss, wound infection, iatrogenic instability, and medical deterioration following lumbar decompression using a tubular retractor system are lower compared to open laminectomy which is quoted in a research study.
In experienced hands, your pain might get significantly reduced by this technique.
Hope your query is answered.
Please do write back if you have any doubts.
Regards,
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dear Dr. Chail
Thanks again for your responses.
I have one last query on this MRI.
Do you see any structural or any other issues in this MRI? For that matter Spondylolisthesis or any other unusual situation?
Best regards
Thanks again for your responses.
I have one last query on this MRI.
Do you see any structural or any other issues in this MRI? For that matter Spondylolisthesis or any other unusual situation?
Best regards
Brief Answer:
There is disc desiccation and small osteophytes and can be considered degenerative changes of lesser importance
Detailed Answer:
Dear Sir,
Thanks for writing back with an update.
There is no other significant abnormality than the one discussed, which could be causing your pain and discomfort.
The vertebrae are aligned and there is no spondylolisthesis.
The discs between the vertebrae show desiccation and this is an acceptable change at your age.
Minor osteophytes are visible along anterior margins of vertebrae which you are already aware of.
Vertebrae show normal expected signal intensities.
Hope your query is answered.
Please do write back if you have any doubts.
Regards,
There is disc desiccation and small osteophytes and can be considered degenerative changes of lesser importance
Detailed Answer:
Dear Sir,
Thanks for writing back with an update.
There is no other significant abnormality than the one discussed, which could be causing your pain and discomfort.
The vertebrae are aligned and there is no spondylolisthesis.
The discs between the vertebrae show desiccation and this is an acceptable change at your age.
Minor osteophytes are visible along anterior margins of vertebrae which you are already aware of.
Vertebrae show normal expected signal intensities.
Hope your query is answered.
Please do write back if you have any doubts.
Regards,
Above answer was peer-reviewed by :
Dr. Sonia Raina
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