Date : 00.00.00
Name of the Patient : Abc Xyza lmn / F / 22 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE since 1 month.
H/O laminectomy at the L4 level with discectomy at the L4-L5 level on 00.00.00.
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.
There are post-operative changes in the posterior soft tissues at the L4 and L5 levels with laminectomy at the L4 level.
There is reduction in the height of the L4-L5 disc.
There is replacement of the normal marrow of the L4 and L5 vertebrae by hypointense areas on the T1 Weighted images. These are seen to turn heterogeneously hyperintense on the T2 Weighted images. There is erosion of the superior and inferior cortical endplates of the L5 and L4 vertebral bodies respectively, with involvement of the L4-L5 intervertebral disc. There is slight pre and paravertebral soft tissue extension of the pathology at the L4 and L5 level.
A hyperintense signal is seen along the left lateral and posterior aspect of the thecal sac at the L4-L5 level on the T1 Weighted images which is seen to turn hyperintense on the T2 Weighted images and would represent granulation tissue. Similar signal intensity is noted in the left lateral recess at the L5 level encasing the left L5 nerve root. The L4-L5 facet joints show degenerative changes.
A posterior disc bulge is seen at the L5-S1 level.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs show normal signal intensity. The rest of the facet joints are unremarkable.
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The conus medullaris terminates at the L1 level and the thecal sac terminates at the S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
17.0 mm at L1-L2
18.0 mm at L2-L3
15.0 mm at L3-L4
12.0 mm at L5-S1.
1. Post-operative status.
2. Altered signal in the L4 and L5 vertebrae with extensions as described most likely represents osteitis.
3. Altered signal along the left lateral and posterior aspect of the thecal sac at the L4-L5 level and L5 level encasing the left L5 nerve root would represent granulation tissue.