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sb/hs/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Nanlmn / M / 46 yrs.
Referred by : Dr. Abc Xyzehta.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE with numbness in BLE (left more than right) since 20 years.
H/O laminectomy with spinal fusion, at the L4-L5-S1 levels in 0000. Revision surgery 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 :

There appears to be sacralization of the L5 vertebra and it is as marked on the film.

There is loss of water content of the L4-L5 intervertebral disc and it is reduced in height.

There is evidence of laminectomy at the L4, L5 and S1 vertebrae with post-operative changes in the soft tissues in the posterior lumbar region at these levels. Slight posterior bulging of the thecal sac at the laminectomy site is noted.


There is a posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level with slight bilateral neural foraminal narrowing. Bilateral far lateral (extraforaminal) disc bulges are seen at this level.



Intermediate signal intensity lesion on the T1 Weighted images is noted in the anterior epidural space to the right of the midline in the right lateral recess of the L5 vertebra with probable encasement of the traversing right L5 nerve root. This lesion is slightly hypointense on the T2 Weighted images. There is no deformation of the thecal sac.

The articular facets at the L3-L4 and L5-S1 levels appear hypertrophied. Mild hypertrophic degenerative changes of the facet joints are noted at the L4-L5 level.

The intrathecal nerve roots over the L4 and L5 vertebral levels are placed slightly anteriorly, when compared to normal. They are however not clumped.

The lumbar vertebral bodies and the remaining intervertebral discs 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 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 :

19.0 mm at L1-L2

20.0 mm at L2-L3

19.0 mm at L3-L4
..3/.













- 3 - Scan-00001


IMPRESSION :

1. Post-operative status.

2. Sacralization of the L5 vertebra.

3. A posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level.

4. Scar tissue in the right lateral recess of the L5 vertebra.

5. Facetal hypertrophy at the L3-L4 and L5-S1 levels.

6. Mild hypertrophic facetal arthropathy at the L4-L5 level.

No previous scans were available for review/comparison.








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