Date : 00.00.00
Name of the Patient : Abc Xyz. Blmn / F / 45 yrs.
Referred by : Dr. Abc Xyzra / Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
H/O L5 laminectomy with L5-S1 discoidectomy done on 00.00.00 for backache radiating to the LLE.
Now C/O right foot drop.
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 are post-operative changes in the posterior soft tissues at the L5 and S1 levels with laminectomy of the L5 and S1 vertebrae and L5-S1 discoidectomy.
An apparent posterior disc herniation (usually seen in immediate post-operative state) with posterior peridiscal osteophyte is seen at the L5-S1 level with anterior indentation of the thecal sac.
An intermediate signal intensity lesion is seen on the T1 Weighted images along the left lateral and posterior aspect of the thecal sac at the L5, L5-S1 and S1 levels. This is seen to turn heterogeneously hyperintense on the T2 Weighted images and represents an inflammatory/scar tissue the result of previous surgery.
Small posterior disc herniations with peridiscal osteophytes are noted at the L2-L3 and L3-L4 levels. Small posterior disc bulge is noted at the L4-L5 level.
Schmorls node is seen in the superior aspect of the L4 vertebral body. The lumbar intervertebral discs show loss of water content.
A small hypointense area is seen on the T1 Weighted images within the conus at the D12 and L1 levels. This is seen to turn hyperintense on the T2 Weighted images and would represent a syrinx/cord edema/myelitis.
Facetal hypertrophy is noted at the L3-L4, L4-L5 and L5-S1 levels.
The lumbar vertebral bodies reveal normal signal intensity. The remaining 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 :
14.0 mm at L1-L2
15.0 mm at L2-L3
10.0 mm at L3-L4
12.0 mm at L4-L5
1. Post-operative status.
2. An apparent posterior disc herniation (usually seen in immediate post-operative period) with posterior peridiscal osteophyte at the L5-S1 level.
- 3 - Scan-00003
3. An intermediate signal intensity lesion along the left lateral and posterior aspect of the thecal sac at the L5, L5-S1 and S1 levels represents an inflammatory/scar tissue, the result of previous surgery.
4. Small posterior disc herniations at the L2-L3 and L3-L4 levels.
5. A syrinx/cord edema/myelitis within the conus at the D12 and L1 levels, ? cause.
As compared to the previous MRI dated 00.00.00, (study no:00000), the patient is now status post-operative at the L5-S1 level. The status of the L2-L3 and L3-L4 discs is unchanged. Changes in the lower dorsal cord/conus medullaris is a new finding.