Date : 00.00.00
Name of the Patient : Abc Xyza. Golmn / F / 11 yrs.
Referred by : Dr. Abc Xyz Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
H/O fall from a height.
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.
There is central and anterior wedging of the L4 vertebra body which is slightly retropulsed. The L4 vertebra shows an ill-defined, hypointense signal on the T1 Weighted images which turns hyperintense on the T2 Weighted images. Break in continuity of the superior endplate of L4 is noted. Probable fracture of the spinous process of L4 is noted. Resultant thecal sac compression is noted at L4.
Anterior wedging of the L1 and L3 vertebrae with altered signal and altered signal of the D12 and D10 vertebra is also noted.
There is an intermediate signal intensity lesion on the T1 Weighted images in the anterior epidural space over the L3 to L5 vertebral levels, which appears relatively hypointense on the T2 Weighted images. This may represent an anterior epidural hematoma, in the given clinical setting. Probable intradural haemorrhage is also noted. Similar signal intensity lesion is also noted in the prevertebral and paravertebral soft tissues over the L1 to L4 vertebral levels, which may also represent soft tissue contusion/hematoma.
The lumbar intervertebral discs and facet joints are unremarkable.
The conus medullaris terminates at the L1 level and the thecal sac terminates at the S1 level.
Subtle hyperintense signal on the T2 Weighted images is noted in the lower dorsal cord at the D12-L1 level, which may represent cord contusion, in the given clinical setting.
Screening T1 Weighted sagittal images of the cervico-dorsal spine shows suspicious signal change of the D7 vertebral body.
1. Wedging of the L1, L3, L4 vertebrae with altered signal of D10, D12, L1, L3 and L4 may suggest wedge fracture with bone bruise, in the given clinical setting.
2. Soft tissue lesion in the anterior epidural space over the L3 to L5 vertebral levels may represent anterior epidural hematoma. Probable intrathecal haemorrhage is also noted.
3. Pre and paravertebral soft tissue over the L1 to L4 vertebral levels may represent soft tissue contusions/hematoma.
4. Compromise of the lumbar canal at the L1 and L4 vertebral levels.
5. Cord signal alteration at the D12-L1 level may represent cord contusion, in the given clinical setting.