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sb/bv/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzkala Melmn / F / 62 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias since 6 months.
H/O L3, L4 and L5 laminectomy with L4-L5 discoidectomy done in June 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. The L4-L5 intervertebral disc is not well-visualized, the sequelae of previous discoidectomy and bone grafting. Fusion of the L4 and L5 vertebral bodies is noted. There is evidence of laminectomy at the L4 and L5 levels with post-operative changes in the soft tissues in the posterior lumbar region at these levels.

The L4 and L5 vertebral bodies appear relatively hypointense when compared to the rest of the vertebrae on the T1 Weighted images and appear isointense on the T2 Weighted images. This may be the sequelae of previous surgery.

A postero-central disc herniation is noted at the L5-S1 level. There is slight retroplacement of the thecal sac at this level.

A left paracentral peridiscal osteophyte is noted at the L4-L5 level.
..2/.






A small posterior disc bulge is noted at the L3-L4 level.

The intrathecal nerve roots at L4 and L5 vertebral levels appear clumped and are placed peripherally. The intrathecal CSF at these levels appears slightly more hyperintense as compared to the normal. These changes may suggest arachnoiditis with a probable arachnoid cyst at the L4 and L5 vertebral levels.

Focal fatty signal within the thecal sac at L3 and L5-S1 levels most likely represents residual intrathecal contrast due to previous myelography.

The facet joints at the L5-S1 level appear hypertrophied.

The rest of 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 L1 level and the thecal sac terminates at the S2 level.

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

12.0 mm at L1-L2
13.0 mm at L2-L3
11.0 mm at L3-L4

IMPRESSION :

1. Post-operative status.

2. A postero-central disc herniation at the L5-S1 level with facetal hypertrophy.
..3/.








- 3 - scan-00007


3. A left paracentral peridiscal osteophyte at the L4-L5 level.

4. Clumped intrathecal nerve roots at L4 and L5 vertebral levels with a probable arachnoid cyst at these levels suggests arachnoiditis.

5. Residual intrathecal contrast at the L3 and L5-S1 levels.




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