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sb/hs/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzal Kaklmn / M / 48 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain in BLE with paresthesias and bladder/bowel involvement since July 0000.
H/O laminectomy at the L4-L5 level in July 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 :

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

Slight retroplacement of the L3 over the L4 and of the L4 over the L5 vertebrae is noted.

There is evidence of laminectomy of the L4 and L5 vertebrae with post-operative changes in the posterior soft tissues at these levels.

A postero-central disc protrusion with peridiscal osteophytes is noted at the L5-S1 level with slight right neural foraminal narrowing.





A small right paracentral disc herniation with peridiscal osteophytes is noted at the L4-L5 level. There is an intermediate signal intensity lesion on the T1 Weighted images in the anterior epidural space on the left at the inferior margin of the L4 vertebral body, at the L4-L5 disc level and in the right lateral recess of the L5 vertebra. This lesion is slightly hypointense on the T2 Weighted images. There is no deformation of the thecal sac.

A small posterior disc herniation with peridiscal osteophytes is noted at the L3-L4 level.

A small postero-central protruded disc is noted at the L2-L3 level.

Postero-central and small left postero-lateral (foraminal) disc herniations are noted at the L1-L2 level.

The articular facets at the L5-S1 level appear hypertrophied. The L3-L4 and L4-L5 facet joints show hypertrophic degenerative changes with resultant bilateral neural foraminal narrowing at these levels.

The intrathecal nerve roots over the L3 to L5 vertebral levels appear clumped suggesting Group I arachnoiditis.

The lumbar vertebral bodies reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12 level and the thecal sac terminates at the S1 level.
..3/.












- 3 - Scan-00009

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

12.0 mm at L1-L2
12.0 mm at L2-L3
9.0 mm at L3-L4

Screening T2 Weighted sagittal images of the dorsal spine shows slight facetal hypertrophy at the D9-D10 and D10-D11 levels.

IMPRESSION :

1. Post-operative status.

2. Slight retroplacement of the L3 over the L4 and of the L4 over the L5 vertebrae.

3. A small right paracentral disc herniation with peridiscal osteophytes the L4-L5 level.

4. Soft tissue lesion in the anterior epidural space on the left at the inferior margin of the L4 vertebral body, at the L4-L5 disc level and in the right lateral recess of the L5 vertebra most likely represents scar tissue.

5. A small posterior disc herniation with peridiscal osteophytes at the L3-L4 level.

6. Postero-central and small left postero-lateral (foraminal) disc herniations at the L1-L2 level.

7. Hypertrophic facetal arthropathy at the L3-L4 and L4-L5 levels.

8. Group I arachnoiditis over the L3 to L5 vertebral levels.








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