Date : 00.00.00
Name of the Patient : Abc Xyz. lmn / M / 43 yrs.
Referred by : Dr. Abc Xyzmtora.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with numbness since 4 months.
H/O laminectomy and discectomy at the L4-L5 and L3-L4 levels in 0000 and 0000. (Details not available).
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.
There is sacralization of the L5 vertebral body and the L2 vertebra is as marked on the film.
The L3-L4 and L4-L5 intervertebral discs show loss of water content.
Post-operative changes are noted in the posterior soft tissues over the L3 to S1 levels with laminectomy of the L4 and L5 vertebral bodies and partial laminectomy of the L3 vertebra.
Small posterior disc herniations with peridiscal osteophytes are noted at the L3-L4 and L4-L5 levels with anterior indentation of the thecal sac and bilateral neural foraminal narrowing.
An intermediate signal intensity is seen in the lateral recesses of the L5 vertebra on the T1 Weighted images and is heterogeneously hyperintense on the T2 Weighted images and may represent scar tissue. There is resultant indentation upon the traversing S1 nerve roots (scans 104.8, 106.5, 6).
The facet joints at the L4-L5 and L3-L4 levels show hypertrophic changes.
The intrathecal nerve roots at the L4-L5 and L5 levels appear slightly thick and would represent Group I arachnoiditis.
The nerve roots at the L2 and L2-L3 levels appear clumped centrally and is suggestive of Group III arachnoiditis.
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 D12 level and the thecal sac terminates at the L5 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
14.0 mm at L1-L2
12.0 mm at L2-L3
9.0 mm at L3-L4
11.0 mm at L4-L5
1. Post-operative changes.
- 3 - Scan-00000
2. Sacralization of the L5 vertebral body.
3. Small posterior disc herniations with peridiscal osteophytes at the L3-L4 and L4-L5 levels.
4. Scar tissue in the lateral recesses of the L5 vertebra bilaterally with resultant indentation upon the traversing S1 nerve roots.
5. Group I arachnoiditis at the L4-L5 and L5 levels and Group III arachnoiditis at the L2 and L2-L3 levels.
6. Hypertrophy of the facet joints atthe L3-L4 and L4-L5 levels.