Date : 00.00.00
Name of the Patient : Abc Xyz Slmn / M / 70 yrs.
Referred by : Dr. Abc Xyzhari.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (right more than left) with paresthesias since January 0000.
H/O pleural effusion on the right side for which patient received AKT for 6 months (6 years ago).
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 lumbar intervertebral discs except the L2-L3 disc.
There is Grade I spondylolisthesis of the L5 over the S1 vertebra with spondylolysis of the L5 vertebra, bilaterally. A resultant pseudo-posterior disc bulge is noted at the L5-S1 level. The L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral disc show Type II degenerative marrow changes.
There is a diffuse hypointense signal on the T1 Weighted images in the L2 and L3 vertebral bodies. This lesion appears hyperintense on the T2 Weighted images. Erosion of the inferior cortical margin of L2 and superior cortical margin of L3 vertebrae is noted with involvement of the L2-L3 disc. There is minimal prevertebral and paravertebral soft tissue lesion at the L2 and L3 vertebral levels and which is of intermediate signal on T1 Weighted images and hyperintense on T2 Weighted images.
A small posterior disc bulge is noted at the L2-L3 level. There is mild retroplacement of the L2 vertebra over the L3 vertebra.
- 2 - scan-00003
Hemangioma with fat content (hyperintense on all the pulse sequences) is noted in the D12 vertebral body.
Facet joints at the L5-S1 level show slight degenerative changes bilaterally. Bilatreral far lateral (extraforaminal) disc bulges are noted at the L5-S1 levels.
The rest of the lumbar vertebral bodies reveal normal signal intensity. The rest of the facet joints are unremarkable.
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
13.0 mm at L2-L3
16.0 mm at L3-L4
15.0 mm at L4-L5
13.0 mm at L5-S1.
Incidentally noted is a cortical renal cyst in the right kidney.
1. Grade I spondylolisthesis of the L5 vertebra over the S1 vertebra with spondylolysis of the L5 vertebra bilaterally. A resultant pseudo-posterior disc bulge is noted at the L5-S1 level.
2. Altered signal of the L2 and L3 vertebral bodies and L2-L3 intervertebral disc suggests osteitis with discitis probably tuberculous in etiology. Minimal prevertebral and paravertebral soft tissue lesion may represent granulation tissue.
The possibility of this lesion representing a neoplasm seems likely.
3. Slight facetal arthropathy at the L5-S1 level.