Date : 00.00.00
Name of the Patient : Abc Xyzy Vlmn / M / 50 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
H/O lumbar spine surgery for tumor (? ependymoma) on 00.00.0000 (details not available) with a cyst formation at the operative site one month later which was removed on 00.00.00.
M.R.I of the lumbo-sacral spine was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted sagittal images.
6 mm thick T1 Weighted and T2 Weighted axial images.
After administration of contrast the following parameters were used :
5 mm thick T1 Weighted axial and coronal images with fat saturation transfer.
6 mm thick T1 Weighted axial images with fat saturation.
There is evidence of operative intervention in the posterior soft tissues in the lumbar region. Probable laminectomy is noted at the L3, L4 and L5 vertebral levels. Metallic susceptibility artifacts are noted in the posterior lumbar region, the result of surgery.
There is seen a lobulated, CSF signal intensity lesion on all the pulse sequences in the posterior epidural space and in the posterior paraspinal soft tissues over L3 to S1 vertebral levels. This lesion is probably in communication with the thecal sac. There is resultant posterior displacement of the spinous processes of the L3, L4 and L5 vertebrae and anterior compression of the intrathecal nerve roots over these levels.
There is near complete removal of the previously identified lesion.
There is loss of water content of the L4-L5 and L5-S1 intervertebral discs.
Small posterior disc bulges are noted at the L4-L5 and L1-L2 levels.
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.
The conus medullaris terminates at the L1 level and the thecal sac terminates at the S2 level.
After contrast administration, there is enhancement along the intrathecal nerve roots over the L3 to S1 vertebral levels. Patchy enhancement is also noted along the posterior paraspinal soft tissues at the operative site.
1. Post-operative status.
2. There is near complete excision of the previously identified tumor.
3. A fairly large, lobulated, CSF intensity lesion on all the pulse sequences in the posterior epidural space and in the posterior paraspinal soft tissues over the L3 to S1 vertebral levels as described, most likely represents a pseudomeningocele.
4. Enhancement along the intrathecal nerve roots over the L3 to S1 vertebral levels may either be due to previous surgery, arachnoiditis or tumor infiltration.
No surgical details were available.