sb/bv/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyza lmn / F / 31 yrs.
Referred by : Dr. Abc Xyzwhale.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE with paresthesias since 6 months.
H/O laminectomy at L4-L5 with discectomy.

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 minimal retroplacement of the L4 over the L5 vertebra. The L4-L5 intervertebral disc shows loss of water content.

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 an apparent posterior disc bulge at the L4-L5 level.

Slight facetal hypertrophy is noted at the L4-L5 and L5-S1 levels.

There is clumping of the nerve roots within the thecal sac centrally suggesting Type II arachnoiditis over the L4 and L5 vertebral levels (scans 106.6 - 106.8, 103.4).
Scan-00001

Slight herniation of the L4-L5 disc into the body of L4 is noted with adjacent Type I degenerative changes.

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 L2 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
19.0 mm at L2-L3
19.0 mm at L3-L4.

IMPRESSION :

1. Post-operative changes.

2. Minimal retroplacement of the L4 over the L5 vertebra with an apparent posterior disc bulge at the L4-L5 level.

3. Clumping of the nerve roots within the thecal sac centrally over the L4 and L5 vertebral levels suggestive of Type II arachnoiditis.