ke/bv/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Plmn / M / 40 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE since 15 days.
H/O laminectomy with discectomy at L3-L4 and L4-L5 levels 1 month back.

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 scoliosis of the lumbar spine with convexity to the left.

Post-operative changes are seen in the posterior soft tissues over the L3 to S1 levels with laminectomy of the L4 and L5 vertebrae.

There is an apparent posterior disc herniation (seen in the immediate post-operative period) at the L3-L4 level with anterior indentation of the thecal sac. Posterior peridiscal osteophytes are also noted at this level. The intrathecal nerve roots at this level appears compressed. The L3-L4 disc also appears more hyperintense on the T2 Weighted images as compared to the previous scan.







There is an intermediate signal intensity area on the T1 Weighted images in the lateral recess of the L4 vertebra which is heterogeneously hyperintense on the T2 Weighted images and would represent granulation tissue. There is resultant encasement of the L4 nerve roots (scans 104.12, 104.14). Another similar intermediate signal intensity lesion is seen in the left lateral recess of L5 vertebra (scan 104.8) with probable encasement of the L5 nerve root.

There is slight irregularity and erosion of the superior cortical endplate of the L4 vertebral body with adjacent hypointense areas on the T1 Weighted images replacing the normal marrow of the L4 vertebral body. These are isointense to the marrow on the T2 Weighted images and would represent post-operative bone-edema.

Small posterior disc bulge is noted at the L4-L5 level with anterior indentation of the thecal sac. The L4-L5 intervertebral disc shows slight loss of water content.

The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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
14.0 mm at L5-S1.
..3/.









- 3 - Scan-00003



IMPRESSION :

The MRI features are suggestive of :

1. Post-operative status with bone edema in the L4 vertebral body.

2. An apparent posterior disc herniation at the L3-L4 level with compression of the intrathecal nerve roots at this level.

3. Granulation tissue at the L4 and L5 levels with encasement of the L4 nerve roots, bilaterally and the left L5 nerve root.