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sb/ke/rg/nl
Date : 00.00.00

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

CLINICAL PROFILE :

C/O backache radiating to BLE.

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 seen an intradural, CSF signal intensity lesion on all the pulse sequences, extending over the L3 to the S1/S2 vertebral levels. The walls of the lesion are not well-defined. The intrathecal nerve roots over the L2 to S2 vertebral levels are displaced anteriorly. The antero-posterior dimension of this lesion is about 11.0 mms. The intrathecal nerve roots are however well-identified separately from each other.

There is slight loss of water content of the L4-L5 and L5-S1 intervertebral discs. Small posterior disc bulges are noted at the L4-L5 and L5-S1 levels.

Facetal hypertrophy is noted at the L3-L4, L4-L5 and L5-S1 levels.

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.


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 :

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

IMPRESSION :

1. An intradural, CSF signal intensity lesion extending over the L3 to the S1/S2 vertebral levels with anterior displacement of the intrathecal nerve roots as described, most likely represents an intradural arachnoid cyst.

The possibility of the intrathecal nerve roots being displaced anteriorly due to arachnoiditis cannot be entirely excluded, though less likely.

2. Small posterior disc bulges at the L4-L5 and L5-S1 levels.

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


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