sb/bv
Date : 00.00.00

Name of the Patient : Abc Xyz V. Vlmn / M / 63 yrs.
Referred by : Dr. Abc Xyzam.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain in BLE (right more than left) with paresthesias since 1 year.
H/O spinal surgery done 3 years back (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 reduction in height of the L4-L5 intervertebral disc and loss of water content of all the lumbar intervertebral discs except the L3-L4 disc.

There is evidence of laminectomy of the L4 and L5 vertebrae with post-operative changes in the soft tissues in the posterior lumbar region at these levels. Evidence of L4-L5 discectomy is noted.

A posterior and bilateral far lateral disc bulge is noted at the L5-S1 level with minimal indentation on the traversing S1 nerve roots bilaterally. Probable inflammation of the left S1 nerve root is noted. Facetal hypertrophy is noted at the L5-S1 level, bilaterally, more on the left side.

A posterior disc bulge and bilateral far lateral disc bulges with peridiscal osteophytes is noted at the L4-L5 level.


Small posterior disc bulges are noted at the L1-L2, L2-L3 and L3-L4 levels.

Fatty marrow changes are noted in the L4 and L5 vertebral bodies.

Irregularity of the endplates adjacent to the L4-L5 intervertebral disc may be the sequelae of previous surgery.

Anterior disc herniations with anterior peridiscal osteophytes are noted in the lumbar region.

The facet joints at the L4-L5 level appear hypertrophied. The rest of the facet joints in the lumbar region also appear slightly hypertrophied.

The intrathecal nerve roots at the L4 and L5 vertebral levels appear clumped suggesting Group I arachnoiditis. The CSF at the L4-L5 disc level, posteriorly, appears slightly more hyperintense when compared to the normal. This may suggest a small intrathecal arachnoid cyst or trapped CSF.

The lumbar vertebral bodies 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 S2 level.

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

13.0 mm at L1-L2
13.0 mm at L2-L3
14.0 mm at L3-L4
..3/.









- 3 - Scan-00004



IMPRESSION :

The MRI features are suggestive of :

1. Post-operative status.

2. A posterior and bilateral far lateral disc bulge at the L5-S1 level with minimal indentation on the traversing S1 nerve roots bilaterally, facetal hypertrophy bilaterally and probable inflammation of the left S1 nerve root.

3. A posterior disc bulge and bilateral far lateral disc bulges with peridiscal osteophytes at the L4-L5 level.

4. Facetal hypertrophy in the lumbar region.

5. Group I arachnoiditis at the L4 and L5 vertebral levels with a probable small intrathecal arachnoid cyst/trapped CSF at the L4-L5 disc level.