sb/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzj Bhlmn / M / 39 yrs.
Referred by : Dr. Abc Xyzorude.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE since February 0000.
H/O lumbar spine surgery in May 0000. (Details not available).

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 sacralization of the L5 vertebra and the L2 vertebral body is as marked on the film.

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 loss of water content of the L4-L5 intervertebral disc.

There is a fairly large, posteriorly extruded disc at the L4-L5 level with thecal sac compression and bilateral neural foraminal narrowing. There is also indentation on the traversing L5 nerve roots bilaterally. Ill-defined intermediate signal on the T1 Weighted images in the epidural space at the L4-L5 and L5 levels, which turns slightly hyperintense on the T2 Weighted images represents granulation tissue/scar tissue, the sequelae of previous surgery. There is encasement of the exiting L5 nerve roots bilaterally by granulation/scar tissue. Slight inferior migration of the disc fragment is also noted at the L4-L5 level.
..2/.




Small, right paracentral protruded disc is noted at the L3-L4 level.

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

Type II degenerative marrow changes are noted in the L5 vertebral body adjacent to the L4-L5 disc.

The rest of 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 D12-L1 level and the thecal sac terminates at the S1 level.

Fat is noted in the filum terminale in the lumbar region.

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

16.0 mm at L1-L2
15.0 mm at L2-L3
14.0 mm at L3-L4

IMPRESSION :

1. Post-operative status.

2. Sacralization of the L5 vertebra.

3. A fairly large, posteriorly extruded disc at the L4-L5 level with bilateral neural foraminal narrowing and indentation on the traversing L5 nerve roots bilaterally.
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- 3 - Scan-00007



4. Scar/granulation tissue in the epidural space at the L4-L5 and L5 levels.

As compared to the previous MRI dated 00.00.00, the patient is now status post-operative.

There is however, no significant change in the degree of disc herniation at the L4-L5 level on the present study.