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sb/ke/nl/rg
Date : 00.00.00

Name of the Patient : Abc Xyzra lmn / M / 60 yrs.
Referred by : Dr. Abc Xyzra.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O low back pain radiating to the LLE with paresthesias since 15 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 loss of normal lumbar lordosis and loss of water content of the lower lumbar intervertebral discs.

There is evidence of laminectomy of the L3 and L4 vertebrae with post-operative changes in the soft tissues in the posterior lumbar region at these levels.

A posterior disc bulge with peridiscal osteophytes is noted at the L5-S1 level with bilateral neural foraminal narrowing and indentation on the S1 nerve roots bilaterally.

A posteriorly bulging disc with peridiscal osteophytes is noted at the L4-L5 level with bilateral neural foraminal narrowing. A disc fragment is noted in the left neural foramen at the L4-L5 level, impinging the left L4 and L5 nerve root.
Scan-00002


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

A very small, fat signal intensity lesion on all the pulse sequences in the thecal sac at the L4 vertebral level, may represent intrathecal contrast globule.

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

The intrathecal nerve roots in the lower lumbar region appear clumped suggesting arachnoiditis.

Fatty marrow changes are noted in the L4 and L5 vertebral bodies.

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 level and the thecal sac terminates at the S1 level.

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

15.0 mm at L1-L2
15.0 mm at L2-L3
9.0 mm at L5-S1.

IMPRESSION :

1. Post-operative status.
..3/.










- 3 - Scan-00002



2. A posterior disc bulge with peridiscal osteophytes at the L5-S1 level with bilateral neural foraminal narrowing and indentation on the S1 nerve roots bilaterally.

3. A posteriorly bulging disc with peridiscal osteophytes at the L4-L5 level with a disc fragment in the left neural foramen at the L4-L5 level, impinging the left L4 and L5 nerve root.

4. A small posterior disc bulge with peridiscal osteophytes at the L3-L4 level.

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

6. Arachnoiditis in the lower lumbar region.

7. Canal stenosis at the L3-L4, L4-L5 and L5-S1 levels.


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