Date : 00.00.00
Name of the Patient : Abc Xyz Ralmn / M / 42 yrs.
Referred by : Dr. Abc Xyzhi.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O low back pain radiating to BLE since 3 months.
H/O spinal surgery 2 years back.
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 loss of water content of the L4-L5 and L5-S1 intervertebral discs.
There is evidence of laminectomy of the L5 vertebra with post-operative changes in the soft tissues in the posterior lumbar region at that level.
There is central and anterior wedging of the L4 vertebral body which appears hypointense on the T1 Weighted images and hyperintense on the T2 Weighted images. Herniation of the L3-L4 disc into the body of the L4 vertebra is noted.
Small, posterior disc herniations with posterior peridiscal osteophytes are noted at the L4-L5 and L5-S1 levels.
The intrathecal nerve roots at the L4, L5 and S1 vertebral levels appear clumped suggesting arachnoiditis (Group I).
- 2 - scan-00002
The rest of the visualized lumbar vertebral bodies show spotty fatty marrow changes. The remaining intervertebral discs reveal normal signal intensity. The facet joints at the L4-L5 and L5-S1 levels appear slightly hypertrophied.
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 S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
15.0 mm at L1-L2
17.0 mm at L2-L3
15.0 mm at L3-L4
13.0 mm at L4-L5
Screening T1 Weighted sagittal images of the dorsal spine reveal spotty fatty marrow changes in some of the dorsal vertebrae.
1. Post-oeprative changes.
2. Central and anterior wedging of the L4 vertebral body
with altered signal is not specific for a single etiology. These changes may suggest,
a. Wedge-fracture with bone bruise.
b. Metastasis/small cell tumors.
A biopsy from the affected bone may be worthwhile.
2. Small, posterior disc herniations with posterior peridiscal osteophytes at the L4-L5 and L5-S1 levels.
3. Spotty fatty marrow of the rest of the lumbar and some dorsal vertebral bodies which may suggest osteoporosis.