Date : 00.00.00
Name of the Patient : Abc Xyz lmn / F / 35 yrs.
Referred by : Dr. Abc Xyzhari.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
H/O fall 15 days back with backache radiating to the RLE since then.
Past H/O lumbar spine surgery 2 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 evidence of laminectomy of the L5 vertebra with post-operative changes in the posterior soft tissues.
There is Grade III spondylolisthesis of the L5 vertebra over the S1 vertebra. There appears to be a break of the pars interarticularis of the L5 vertebra bilaterally. A pseudoposterior disc herniation is noted at the L5-S1 level. Also seen is an anterior disc herniation at this level.
There is anterior wedging of the D12 vertebral body. Linear hypointensities on all the pulse sequences within it may represent compressed trabeculae. Diffuse hypointense signal on the T1 Weighted images which turns hyperintense on the T2 Weighted images is seen within the D12 vertebral body, which may represent bone edema.
A posterior disc bulge is noted at the L4-L5 level.
There is dilatation of the abdominal aorta from the D12-L1 level downwards with dilatation of the proximal left common iliac artery.
The lumbar intervertebral discs show loss of water content.
Extensive Type II degenerative changes are seen within the L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral disc.
The rest of the lumbar vertebral bodies reveal normal signal intensity. The facet joints and 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.
1. Post-operative status.
2. Grade III spondylolisthesis of the L5 vertebra over the S1 vertebra with probable spondylolysis of the L5 vertebra bilaterally.
3. Compression fracture of the D12 vertebral body, especially in the given clinical setting of a fall.
4. Aneurysmal dilatation of the abdominal aorta from the D12-L1 disc level upto the proximal iliac vessels.