sb/bv/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzang Plmn / M / 42 yrs.
Referred by : Dr. Abc Xyzar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain in BLE (left more than right) with paresthesias since 4-5 months. Also C/O gait ataxia with slipping off of chappals.
H/O laminectomy at L3-4-5 levels in 0000.

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, 5 mm thick T1 Weighted axial images and 3 mm thick T1 Weighted coronal images with fat saturation were obtained.

OBSERVATION :

There is loss of water content of all the lumbar intervertebral discs except the L2-L3 disc.

There is slight retroplacement of the L3 over the L4 and L1 over the L2 vertebrae.

There is evidence of laminectomy of the L3, L4 and L5 vertebrae with post-operative changes in the posterior lumbar region over these levels.

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


A posterior disc bulge with a left paracentral disc herniation is noted at the L4-L5 level with bilateral neural foraminal narrowing and indentation on the traversing left L5 nerve root.

A posteriorly herniated disc is noted at the L3-L4 level with bilateral neural foraminal narrowing. An anterior disc herniation is also seen at this level.

A postero-central disc herniation with peridiscal osteophytes is noted at the L1-L2 level.

Hypertrophic facetal arthropathy is noted at the L3-L4, L4-L5 and L5-S1 levels and facetal hypertrophy is noted at the L2-L3 level. A bony bar is noted along the posterior margin of the thecal sac at the L3-L4 level with canal stenosis. The intrathecal nerve roots at the L5 and S1 levels appear plastered to the thecal sac, peripherally suggesting Group II arachnoiditis.

There is seen a CSF intensity lesion on all pulse sequences within the lower dorsal spinal cord at the D11 and D12 vertebral levels. Septae are noted within this lesion. Slight effacement of the CSF space is noted over these levels.

There is slight anterior wedging of the D12 and L1 vertebral bodies with diffuse fatty marrow changes.

The rest of the lumbar vertebral bodies 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-L2 level and the thecal sac terminates at the S2 level.
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- 3 - Scan-00003



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

10.0 mm at L1-L2
14.0 mm at L2-L3

After administration of contrast, there is no focal area of abnormal enhancement within the visualized lower dorsal spinal cord or the meninges. No enhancing lesion is noted on the T1 Weighted sagittal images of the dorsal spine.

IMPRESSION :

1. Post-operative status.

2. Slight retroplacement of the L3 over the L4 and L1 over the L2 vertebrae.

3. A postero-central disc herniation at the L5-S1 level.

4. A posterior disc bulge with a left paracentral disc herniation at the L4-L5 level with indentation on the traversing left L5 nerve root.

5. A posteriorly herniated disc at the L3-L4 level with a bony bar, posteriorly, with canal stenosis.

6. A postero-central disc herniation with peridiscal osteophytes at the L1-L2 level.

7. Hypertrophic facetal arthropathy at the L3-L4, L4-L5 and L5-S1 levels and facetal hypertrophy at the L2-L3 level.
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- 4 - Scan-00003




8. Group II arachnoiditis at the L5 and S1 vertebral levels.

9. A non-enhancing, CSF intensity lesion on all pulse sequences within the lower dorsal spinal cord at the D11 and D12 vertebral levels, is not specific for a single etiology. A syrinx/arachnoid cyst due to arachnoiditis may be considered as a differential diagnosis. The possibility of a neoplasm seems less likely.