hs/ke/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzs Castelmn / M / 34 yrs.
Referred by : Dr. Abc Xyzhijwala.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE (left more than right) with paresthesias since 1 1/2 months.
H/O spine surgery in the past.

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 of the L4, L5 and S1 vertebrae with post-operative changes in the posterior soft tissues at these levels.

There is mild retrolisthesis of the L4 over the L5 vertebrae. The L4-L5 and L5-S1 intervertebral discs shows loss of water content.

A small postero-central disc herniation is seen to indent the thecal sac at the L4-L5 level. The L4-L5 facet joints show hypertrophic degenerative changes.

Hypointense areas on the T1 Weighted images which show an intermediate signal intensity on the T2 Weighted images within the anterior epidural space at the L5 vertebral level with encasement of the traversing L5 nerve roots bilaterally. This most likely represents a scar tissue.


The intrathecal nerve roots at the L4 and L5 levels are thickened and irregularly defined suggestive of Group I arachnoiditis.

A small postero-central disc protrusion is noted at the L5-S1 level.

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 S2 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
18.0 mm at L2-L3
16.0 mm at L3-L4

IMPRESSION :

The MRI features are suggestive of :

1. Post-operative status.

2. Small postero-central disc herniation at the L4-L5 level.

3. Scar tissue within the anterior epidural space at the L5 vertebral level with encasement of the traversing L5 nerve roots bilaterally.

4. Hypertrophic facetal arthropathy at the L4-L5 level.

5. Group I arachnoiditis at the L4 and L5 levels.