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Name of the Patient : Abc Xyzt Hulmn / M / 50 yrs.
Referred by : Dr. Abc Xyzdhwa / Dr. Abc Xyzan.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

H/O spine surgery 1 month back.
C/O paraplegia with bladder/bowel involvement since then.

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 L5 vertebral levels with post-operative changes in the soft tissues in the posterior lumbar region over these levels. The posterior paraspinal muscles over these levels show an intermediate signal on the T1 Weighted images which appears diffusely hyperintense on the T2 Weighted images. Scar of the previous surgery is noted in the posterior subcutaneous tissues. The region along the posterior margin of the thecal sac over the L3 to L5 vertebral levels appears more hyperintense than the adjacent soft tissues (? gel foam ?? small collection). The margins of the thecal sac over the operative site are not well-defined.

The intrathecal CSF over the L3 to S1 vertebral levels appear more hyperintense as compared to normal on all the pulse sequences. The intrathecal nerve roots over these levels are not well-identified separately.

Diffuse hypointense signal on the T1 Weighted images is noted in the L3 and L4 vertebral bodies, posteriorly and more to the left of the midline. These lesions appear hyperintense on the T2 Weighted images.
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The L2-L3, L3-L4 and L4-L5 intervertebral discs show slight loss of water content.

Posteriorly bulging discs with peridiscal osteophytes are noted at the L3-L4 and L4-L5 levels.

The rest of 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 S1 level.

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

18.0 mm at L1-L2
17.0 mm at L2-L3

Screening, T2 weighted sagittal images of the cervico-dorsal region do not reveal any significant feature of note.

Screening, T2 Weighted axial images of the brain reveal mild fullness of both the lateral ventricles. No other significant abnormality is detected.

IMPRESSION :

1. Post-operative status.

2. Diffuse altered signal posterior paraspinal muscles over L3 to L5 vertebral levels may be post-operative changes or infective/inflammatory changes.

3. Altered signal along the posterior margin of the thecal sac over the L3 to L5 vertebral levels is ? gel foam ?? small collection.
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4. Altered signal of the intrathecal CSF over the L3 to S1 vertebral levels with non-differentiation of the
intrathecal nerve roots over these levels suggests arachnoiditis.

5. Altered signal in the L3 and L4 vertebral bodies, posteriorly and more to the left of the midline is ? due to osteitis.

As compared to the previous MRI dated 00.00.00, the patient is now status post-operative. There is decrease in the degree of thecal sac compression at the L3-L4 and L4-L5 levels.


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