sb/bv
/00008 Date : 00.00.00

Name of the Patient : Abc Xyza lmn / M / 48 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Dorsal & Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain in the RLE since March 0000.
H/O laminectomy with discectomy done at L3/L4/L5 levels in August 0000.

EXAMINATION :

M.R.I of the dorsal and 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 :

The L5 vertebra is as marked on the film.

There is loss of water content of the dorsal and lumbar intervertebral discs.

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

There is a diffuse intermediate signal on the T1 Weighted images in the posterior soft tissues in the lumbar region at the operative site. This turns hyperintense on the T2 Weighted images. This most likely represent scar tissue/granulation tissue, the sequelae of previous surgery. The posterior margin of the thecal sac is ill-defined. This scar/granulation lesion is seen to extend into the spinal canal laterally, at the laminectomy site and is seen to encase the thecal sac at the L4 and L4-L5 levels. The intrathecal nerve roots over L1 to L3 vertebral levels are clumped, suggesting arachnoiditis. Scar ..2/.



- 2 - scan-00008


tissue is also noted along the S1 nerve roots bilaterally.

The L4-L5 disc is reduced in height and shows evidence of posterior peridiscal osteophytes which is most likely the sequelae of previous discectomy. Bilateral neural foraminal narrowing is noted.

A posteriorly bulging disc with peridiscal osteophyte is noted at the L3-L4 level with bilateral neural foraminal narrowing. A bony bar is noted at the L3-L4 disc level, posteriorly with canal stenosis.

A left and right postero-lateral disc herniation is noted at the L2-L3 level with bilateral neural foraminal narrowing.

A posterior peridiscal osteophyte is noted at the L1-L2 level.

The mid-dorsal intervertebral discs are slightly reduced in height. A small posterior disc bulge is noted at the D10-D11 level.

A hemangioma with fat content is noted in the D5 vertebral body.

Type II degenerative marrow changes are noted adjacent to the L4-L5 intervertebral disc.

The facet joints at the L2-L3, L4-L5 and L5-S1 levels appear slightly hypertrophied.

The rest of the dorsal and lumbar vertebral bodies reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.

The visualized dorsal spinal cord reveal normal signal intensity.

The conus medullaris terminates at the L1 level and the thecal sac terminates at the S1 level.
..3/.







- 3 - scan-00008


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 :

1. Post-operative status.

2. Altered signal in the posterior soft tissues in the lumbar region at the operative site most likely represent scar tissue/granulation tissue, the sequelae of previous surgery.
Extension of the scar tissue into the spinal canal laterally, at the laminectomy site is noted with encasement of the thecal sac at the L4 and L4-L5 levels and with encasement of the S1 nerve roots.

3. Arachoid over L1 to L3 vertebral levels.

4. Posterior peridiscal osteophytes at L4-L5 level with bilateral neural foraminal narrowing.

5. A posteriorly bulging disc with peridiscal osteophyte at the L3-L4 level.

6. A left and right postero-lateral disc herniation at the L2-L3 level with bilateral neural foraminal narrowing.

7. Slight hypertrophy of the facet joints at the L2-L3, L4-L5 and L5-S1 levels.

8. Canal stenosis at L2-L3 and L3-L4 levels.

As compared to the previous MRI (study no. 0000) dated 00.00.00, the patient is now status post-operative. The L4-L5 disc is reduced in height due to previous discectomy. Stenotic canal is still noted at the L2-L3 and L3-L4 levels.