可做手術嗎？

病患者女 - 44歲

MR CERVICAL SPINE CLINICAL HISTORY; Back & neck injury after a fall on back recently. Left LL rad. pain. Swelling++ spasm++. ? PID L/C spine. JECHNJOUE; Sagittal: Tl, T2, T2*GRE Axial: T2*GRE(C3-Tl), T2/FS(C3-Tl)

Summary FINDINGS; There is a loss of lordosis due to muscular spasm. The cervical alignment is otherwise unremarkable and posterior alignment is smooth. There is no abnormal signal seen in the vertebral bodies. There is no increased signal on T2 FS images to suggest bone oedema or bone contusion. A fracture is also not seen. Disc space is narrowed at C4/5, C5/6 and C6/7. Signal loss is seen at C4/5, C5/6 and C617cervical discs due to degeneration and dehydration. No abnormal signal in the end-plate. No evidence of discitis. At C3/4, central disc protrusion is seen with thecal sac indentation. At C4/5, broad base disc protrusion is seen with thecal sac indentation and posterior osteophytes.

At CS/6, broad base right lateral disc protrusion is seen with encroachment of right exit foramen and thecal sac indentation. At C6l7, broad base bilateral disc protrusion is seen with encroachment of both exit foramen and thecal sac indentation. There is no abnormality seen in the posterior apophyseal joints. No thickening is seen. There is no abnormal signal in the cord. The dural sac is also normal. There is no abnormality seen in the paravertebral region. No paravertebra1 soft tissue swelling or oedema is seen. COMMENT:
l. C3/4 central disc protrusion with theca1 sac indentation.
2. C4/5, broad base disc protrusion with theca1 sac indentation and posterior osteophytes.
3. C5/6, broad base right lateral disc protrusion with encroachment of right exit foramen and theca1 sac indentation.
4. C6l7, broad base bilateral disc protrusion with encroachment of both exit foramen and thecal sac indentation.

MR LUMBAR SPINE CLINICAL HISTORY: Back & neck injury after a fall on back recently. Left LL rad. pain. Swelling++ spasm++. ? PID L/C spine. TECHNIQUE: Sagittal: Tl, T2, T2/FS Axial: Tl(L3-Sl), T2(L3-Sl) Summary FINDINGS: There is a loss of lordosis due to muscular spasm. The posterior alignment is smooth. Subcutaneous soft tissue swelling and oedema are seen at the back from L 1 to S 1. There is no abnormal signal seen in the vertebral bodies. There is no increased signal on T2 FS images to suggest bone oedema or bone contusion. A fracture is also not seen. There is no disc space narrowing. There is signal loss on T2 at L4/5 lumbar disc due to degeneration and dehydration. There is mild posterior facet joints thickening. At L4/5, substantial central left lateral disc protrusion 1s seen with thecal sac indentation. Encroachment of both exit foramen noted.
There is no abnormal signal in the cord. The conus ends at the L 1 level. The cauda equina appeared unremarkable. The spinal canal is capacious and no canal stenosis is detected. There is no abnormality seen in the paravertebral region. No paravertebral soft tissue swelling or oedema is seen. COMMENT: 1. Desiccated L4/5 disc. 2. Mild posterior facet joints thickening. 3. L4/5 substantial central left lateral disc protrusion with thecal sac indentation and encroachment of both exit foramen.

陳禮樂醫生回覆:
10/7/2018

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