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sb/bv/rg/nl
Date : 00.00.00

Name of the Patient : Abc XyzA. Al-halmn / M / 46 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

H/O laminectomy at L4/L5 levels 8 months back.
C/O backache radiating to the BLE since 3 days.

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 slight scoliosis of the lumbar spine with convexity to the right.

There is evidence of laminectomy at the L4 and L5 vertebral levels with post-operative changes in the soft tissues in the posterior lumbar region at these levels. Probable discectomy at the L4-L5 level is noted. The thecal sac is slightly retroplaced and appears slightly larger in diameter at the operative site. The margins of the thecal sac at L4-L5 and L5 levels cannot be differentiated from the scar tissue/granulation tissue around the thecal sac at these levels.
There is loss of water content of the L5-S1 and L1-L2 intervertebral discs.
The L4-L5 intervertebral disc appears hyperintense on the T2 Weighted images (when compared to the previous MRI dated 00.00.00), probably the result of post-operative changes.


A small apparent right paracentral disc herniation is noted at the L4-L5 level. The right L5 nerve root appears slightly larger in diameter as compared to the normal (scans 104.5-6, 102.6) and is ? inflamed.
There is a small, postero-central protruded disc with a peridiscal osteophyte at the L5-S1 level. A posterior peridiscal osteophyte with a disc bulge is seen at the L1-L2 level. The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.Fat is noted in the filum terminale at the L2 and L3 vertebral levels.The conus medullaris terminates at the D12-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 :21.0 mm at L1-L218.0 mm at L2-L321.0 mm at L3-L4IMPRESSION :1. Post-operative status.

2. A small apparent right paracentral disc herniation at the L4-L5 level.
..3/.









- 3 - Scan-00000



3. Presence of scar/granulation tissue around the thecal sac at the L4-L5 level.

4. Slight larger diameter of the right L5 nerve root as compared to the normal is ? due to nerve root inflammation.
4. Altered signal in the L4-L5 intervertebral disc is ? due to discoidectomy.



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