ke/bv/rg/nl
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.
(Post-contrast study).
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.
For follow up.
EXAMINATION :
5 mm thick T1 Weighted sagittal images with fat saturation through the region of interest.
M.R.I of the lumbo-sacral spine was performed after contrast administration using the following parameters :
5 mm thick T1 Weighted sagittal images.
6 mm thick T1 Weighted axial images.
OBSERVATION :
There is enhancement in the posterior soft tissues and the subcutaneous region over the L2 to the S2 level.
There is no evidence of enhancement in the lower dorsal spinal cord, conus or around the Syrinx. No mass lesion is noted.
The intrathecal nerve roots are seen to enhance within the thecal sac.
There is enhancement of the granulation/scar tissue at the L5-S1 and S1 levels with encasement of the left S1 nerve root.
Enhancement is seen adjacent to the cortical endplates of the L5 and S1 vertebrae.