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Date : 00.00.00

Name of the Patient : Abc Xyzam B. Hulmn / M / 40 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

H/O fall from a height of 10 feet on 00.00.00 followed with backache, radiating to BLE
and paresthesias and weakness in BLE since then.

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.

4 mm thick T1 Weighted coronal images.

OBSERVATION :

There is slight forward subluxation of the L5 over the S1 vertebra with a pseudoposterior disc bulge at the L5-S1 level. Small bilateral far lateral disc bulges are also noted at this level. This disc shows a hyperintense signal on all the pulse sequences which may represent calcification or paramagnetic substance deposition.

The L3-L4 intervertebral disc shows slight loss of water content.

There is evidence of a fracture of the S2 vertebral segment with a kyphus at that level.
There is an ill-defined, hypointense signal on the T1 Weighted images in the sacral segments, which appear hyperintense on the T2 Weighted images. The fat plane around the left S1 nerve root in the left sacral foramen at S1-S2 level is not well-defined. The sacro-iliac joints on either side are unremarkable. A subcentimeter, hypointense focus on all pulse sequences in the sacrum on the right, near the right sacro-iliac joint represents a bone island.

The lumbar vertebral bodies and the remaining intervertebral discs show normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
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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 :

17.0 mm at L1-L2

17.0 mm at L2-L3

14.0 mm at L3-L4

14.0 mm at L4-L5

16.0 mm at L5-S1.

The dorsal spine was screened with 5 mm thick T2 Weighted sagittal images and which does not reveal any significant feature of note.

IMPRESSION :

1. Slight forward subluxation of the L5 over the S1 vertebra with a pseudoposterior disc bulge and small bilateral far lateral disc bulges at the L5-S1 level.

2. Fracture of the S2 vertebral segment with altered signal in the sacral segments suggesting bone bruise.

3. Loss of fat plane around the left S1 nerve root in the left sacral foramen at the S1-S2 level which may suggest nerve root entrapment.
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