sb/hs/nl/nl
Date : 00.00.00
Name of the Patient : Abc Xyz I. Mlmn / F / 63 yrs.
Referred by : Dr. Abc Xyzcha.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE with paresthesias since 1 1/2 months.
H/O left sided hemiparesis.
H/O laminectomy - lumbar exploration with L4-L5 interbody fusion and lateral fusion with bone grafts in December 0000 and March 0000.
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 evidence of laminectomy over the L3 to S1 vertebral levels with discoidectomy of the L4-L5 disc and post-operative changes in the soft tissues in the posterior lumbar region over these levels. Susceptibility artifacts are noted along the posterior margin of the L4-L5 disc to the right of the midline, the sequelae of previous discoidectomy.
There is loss of water content of the L3-L4 and L5-S1 intervertebral discs with a bright signal in the L4-L5 disc space on the left on the T2 Weighted images.
There is a small, postero-central disc herniation at the L5-S1 level with a sequestered disc fragment in the anterior epidural space to the left of the midline, indenting the traversing left S1 nerve root.
There is a fairly large, sequestered disc fragment in the left neural foramen at the L4-L5 level and in the left lateral recess of the L4 vertebra, impinging the left L4 nerve root. Bilateral far lateral disc bulges are also noted at this level.
A small posterior disc bulge is noted at the L3-L4 level.
The facet joints at the L3-L4, L4-L5 and L5-S1 levels show hypertrophic degenerative changes.
The intrathecal nerve roots over the L3 to L5 vertebral levels appear clumped, suggesting arachnoiditis.
Type II degenerative marrow changes are noted adjacent to the L5-S1 disc. The left iliac bone is hypointense on the T1 Weighted images and may be the result of previous surgery (for bone grafts).
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 S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
16.0 mm at L1-L2
15.0 mm at L2-L3
IMPRESSION :
1. Post-operative status.
..3/.
- 3 - Scan-00008
2. A small, postero-central disc herniation at the L5-S1 level with a sequestered disc fragment in the anterior epidural space to the left of the midline, indenting the traversing left S1 nerve root.
3. A fairly large, sequestered disc fragment in the left neural foramen at the L4-L5 level and in the left lateral recess of the L4 body, impinging the left L4 nerve root.
4. Bilateral far lateral disc bulges at the L4-L5 level.
5. Arachnoiditis over the L3 to L5 vertebral levels.