Name of the Patient : Abc Xyzca Lawrlmn / M / 41 yrs.
Referred by : Dr. Abc Xyzni / Dr. Abc Xyzhijwala.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE.
H/O spinal surgery with bone grafting in August 0000.
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 is loss of water content of the L3-L4, L4-L5 and L5-S1 intervertebral discs.
There is slight forward translation of the L5 over the S1 vertebra.
There is evidence of laminectomy at the L5 and S1 vertebral levels with post-operative changes in the soft tissues of the lower back. There is slight retroplacement of the thecal sac at the operative site.
Hypointense signal is seen along the posterior margin of the thecal sac at the L5-S1 level which turns hyperintense on the T2 Weighted images and probably represents granulation/scar tissue. Another similar signal intensity lesion is seen encasing the right S1 nerve root.
There is hypertrophy of the facet joints at the L4-L5, L3-L4 and L2-L3 levels.
A left paracentral disc bulge is noted at the L3-L4 level and a posterior disc bulge is seen at the L2-L3 level.
There is presence of susceptibility artifacts at the L5-S1 level probably the result of surgery and bone grafting. Hyperintense signal on the T2 Weighted is seen in the erector spinae group of muscles probably the result of previous surgery.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of 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 :
14.0 mm at L1-L2
14.0 mm at L2-L3
13.0 mm at L3-L4
11.0 mm at L4-L5
11.0 mm at L5-S1.
1. Post-operative status.
2. Presence of scar granulation/tissue along the posterior margin of the thecal sac at the L5-S1 level and encasing the right S1 nerve root.