Date : 00.00.00
Name of the Patient : Abc XyzHajlmn / M / 37 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Dorso-lumbar Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (right more than left).
H/O fall 1 year back.
H/O Sheurmanns disease 20 years back for which laminectomy of D11, D12 and L1 was done.
M.R.I of the dorso-lumbar spine was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted sagittal images.
6 mm thick T1 Weighted and T2 Weighted axial images.
There is anterior wedging of the D12 vertebral body with a kyphus at that level. The D11-D12 and D12-L1 intervertebral discs show loss of water content. Minimal anterior wedging of the D11 and L1 vertebral bodies is also noted. Anterior peridiscal osteophytes are noted at the D11-D12 and D12-L1 levels.
There is evidence of laminectomy at the D11 and D12 levels, with post-operative changes in the soft tissues in the posterior dorso-lumbar region at these levels.
There is slight compromise of the dorso-lumbar canal at the D12 and L1 levels due to the kyphus. Posteriorly bulging discs with posterior peridiscal osteophytes are noted at the D11-D12 and D12-L1 levels.
The D11, D12 and L1 vertebral bodies show spotty fatty marrow changes.
The facet joint on the right side at the D12-L1 level appears slightly hypertrophied. The visualized pre and paravertebral soft tissues are unremarkable.
The visualized lower dorsal spinal cord reveals normal signal intensity.
The conus medullaris terminates at the D11-D12 level.
The T1 Weighted sagittal images of the lumbo-sacral region do not reveal any significant feature of note.
1. Post-operative status.
2. Anterior wedging of the D12 vertebral body with a kyphus at that level. Slight compromise of the dorso-lumbar canal at the D12 and L1 levels is noted.
3. Posterior disc bulges with posterior peridiscal osteophytes at the D11-D12 and D12-L1 levels.
4. Slight facetal hypertrophy on the right side at the D12-L1 level.