hs/ke/rg.
Date : 00.00.00

Name of the Patient : Abc XyzMohd. Jlmn / F / 52 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with radiation of pain to the LLE since 1 year.
H/O previous surgery in September 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.

OBSERVATION :

There is evidence of laminectomy of the L3 to S1 vertebrae with post-operative changes in the posterior soft tissues over these levels.

The L3-L4, L4-L5 and D10-D11 intervertebral discs show loss of water content.

Areas of hypointensity on the T1 Weighted images which show mixed signal characteristics on the T2 Weighted images are seen within the anterior epidural space at the L4 and L5 vertebral levels with encasement of the traversing L4 and L5 nerve roots. This most likely represents granulation /scar tissue.

There is slight thickening of the intrathecal nerve roots at the L4 levels suggestive of Group I arachnoiditis.

The lumbar facet joints show degenerative changes.

Posterior disc bulges are noted at the L3-L4, L4-L5 and L5-S1 levels.
..2/.






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 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

IMPRESSION :

The MRI features are suggestive of :

1. Post-operative status.

2. Granulation/scar tissue at the L4 and L5 vertebral levels with encasement of the traversing L4 and L5 nerve roots bilaterally.

3. Group I arachnoiditis at the L4 level.