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Name of the Patient : Abc Xyz Dlmn / F / 50 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

H/O backache with pain radiating to BLE with numbness since 0000. L5/S1 laminectomy and discectomy was done on 00.00.00.
C/O bladder/bowel dysfunction 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.

After administration of contrast 5 mm thick T1 Weighted sagittal images (with fat saturation) and 5 mm thick T1 Weighed axial images (with fat saturation) were obtained.

OBSERVATION :

There is probable sacralization of the L5 vertebra which is as marked on the film. Kindly correlate with plain radiographs and the previous MRI, which were not available for review/comparison.

There is loss of water content of the L3-L4 and L4-L5 intervertebral discs.

There is evidence of laminectomy at the L4 and L5 vertebral levels with post-operative changes in the soft tissues in the posterior lumbar region at these levels.

There is a posteriorly bulging disc with peridiscal osteophytes at the L4-L5 level with bilateral neural foraminal narrowing. Facetal hypertrophy is noted at this level, bilaterally with lateral recess stenosis.
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The posterior and lateral margins of the thecal sac at the L4-L5 level are not well-defined. The intrathecal nerve roots at the L4 and L5 vertebral levels appear clumped, suggesting Group I arachnoiditis. Type II degenerative changes are noted adjacent to the L4-L5 intervertebral disc.

A small posterior disc bulge with peridiscal osteophytes is noted at the L3-L4 level with slight facetal and ligamentum flavum hypertrophy and a tight canal at that level.

Slight facetal hypertrophy is also noted in the rest of the lumbar region.

The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12-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 :

15.0 mm at L1-L2
19.0 mm at L2-L3
14.0 mm at L3-L4
11.0 mm at L5-S1.

After administration of contrast, there is enhancement along the posterior and lateral margins of the thecal sac at the L4-L5 and L5 levels. There is also enhancement of the clumped intrathecal nerve roots at L4-L5, L5 and S1 levels.

IMPRESSION :

1. Post-operative status.

2. Probable sacralization of the L5 vertebra which is as marked on the film. Kindly correlate with plain radiographs.
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- 3 - Scan-00007


3. A posteriorly bulging disc with peridiscal osteophytes at the L4-L5 level with facetal hypertrophy at this level, bilaterally and lateral recess stenosis.

4. Enhancement along the posterior and lateral margins of the thecal sac at the L4-L5 level and L5 levels suggests scar tissue.

5. Clumped, enhancing intrathecal nerve roots at the L4-L5, L5 and S1 levels suggests Group I arachnoiditis.

6. A small posterior disc bulge with peridiscal osteophytes at the L3-L4 level with slight facetal and ligamentum flavum hypertrophy and a tight canal at that level.

7. Slight facetal hypertrophy in the rest of the lumbar region.

The previous MRI films and plain radiographs were not available for review/comparison.
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