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ke/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzh Sonalmn / M / 53 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O weakness of BLE with bladder involvement since 3 years.

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 :

The lumbar facets joints show mild degenerative changes.

Schmorls node is noted at the L2-L3 level. The L2-L3 and L3-L4 intervertebral discs show loss of water content. The L2-L3 disc is also reduced in height.

There is increase in the epidural fat over the L3 to L5 levels giving the thecal sac a trifoliate appearance which can be seen with epidural lipomatosis. The intrathecal nerve roots appear clumped, in the lumbar region.

Type II degenerative changes are seen in the L2 and L3 vertebral bodies adjacent to the L2-L3 intervertebral disc. Slight anterior wedging of the L1 vertebra with fatty change is noted.

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


The conus medullaris terminates at the L1-L2 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 :

18.0 mm at L1-L2
18.0 mm at L2-L3
17.0 mm at L3-L4
16.0 mm at L4-L5
15.0 mm at L5-S1.

IMPRESSION :

1. Degenerative changes of the lumbar facets joints.

2. Epidural lipomatosis over the L3 to L5 levels.

3. Clumped intrathecal nerve roots in the lumbar region is ? due to epidural lipomatosis, ?? due to arachnoiditis (due to tuberculous meningitis)

A contrast enhanced scan would be worthwhile to rule out arachnoiditis if clinicallly indicated.

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