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sb/ke/nl/rg.
Date : 00.00.00

Name of the Patient : Abc XyzBalmn / F / 44 yrs.
Referred by : Dr. Abc Xyzralay.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE since 15 days.
H/O backache radiating to the LLE with paresthesias in March 0000. Spinal surgery done on 00.00.00. Details not available.

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 (with fat saturation) axial images.

OBSERVATION :

There is slight retrolisthesis of the L5 vertebra over the S1 vertebra.

There is evidence of operative intervention in the soft tissues in the posterior lumbar region at L5 and S1 vertebral levels. There is effacement of the fat planes around the paraspinal muscles on the left at the S1 vertebral level. There is seen an approximately 3.0 x 3.8 x 4.0 cms sized well-marginated, intermediate signal intensity mass lesion on T1 Weighted images in the soft tissues in the posterior lumbar region within the subcutaneous fat in the midline, extending over the L5 and S1 vertebral levels. This lesion appears hyperintense on the T2 Weighted images. A focal, hyperintense signal on T1 Weighted images is noted within this lesion, which appears hypointense on the T2 Weighted images. This lesion probably tracks upto the spinal canal at the L5-S1 level.

There is still seen a posterior disc extrusion with peridiscal osteophyte at the L5-S1 level with anterior indentation of the thecal sac. There is inferior migration of the disc fragment with indentation upon the traversing S1 nerve roots (left more than right). Intermediate signal in the left lateral and posterior epidural space at the L5-S1 level may represent scar tissue. The L5-S1 facet joints show mild degenerative changes with slight effusion on the right side. There is bilateral neural foraminal narrowing at this level.

A postero-central disc herniation is noted at the L4-L5 level with anterior indentation of the thecal sac. The L4-L5 facet joints also show mild degenerative change.

Anterior disc herniations are noted at the L1-L2, L2-L3, L3-L4 and L5-S1 levels. The L4-L5 and L5-S1 intervertebral discs show loss of water content.

Type II degenerative changes are seen in the L5 and S1 vertebrae adjacent to the L5-S1 intervertebral disc and at the antero-superior aspect of the L3 and L4 vertebral bodies.

The rest of 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.

A cortical renal cyst is noted on the left side.

The conus medullaris terminates at the L1 level and the thecal sac terminates at the S1 level.
..3/.












- 3 - Scan-00004

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

14.0 mm at L1-L2
14.0 mm at L2-L3
14.0 mm at L3-L4
9.0 mm at L4-L5
9.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. Post-operative status.

2. An approximately 3.0 x 3.8 x 4.0 cms sized mass lesion in the posterior subcutaneous fat at the L5 and S1 levels as described most likely represents a posterior collection/abscess, in the given clinical setting. Altered signal intensity lesion within this collection may represent fat globules.

3. A posterior disc extrusion with peridiscal osteophytes at the L5-S1 level with inferior migration of the disc fragment and indentation on the traversing S1 nerve roots (left more than right) with mild facetal arthropathy at this level.

3. A postero-central disc herniation at the L4-L5 level with mild facetal arthropathy at this level.

4. Probable scar tissue in the thecal sac at the L5-S1 level.

As compared to the previous MRI (scan no.00009) dated 00.00.00, the patient is now status post-operative. There is however no significant change in the degree of disc herniation at the L4-L5 and L5-S1 levels.




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