Date : 00.00.00
Name of the Patient : Abc Xyz V. Varlmn / M / 85 yrs.
Referred by : Dr. Abc Xyzonawalla.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
H/O fall 1 year ago.
C/O backache radiating to BLE with paresthesias since 8 days.
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 scoliosis of the lumbar spine with slight convexity to the right.
There is wedging of the L3 vertebral body which shows hypointense signal replacing the normal marrow on the T1 Weighted images. This is seen to turn heterogeneously hyperintense on the T2 Weighted images. There is slight bulging of the vertebral body in the pre and paravertebral soft tissues which is hyperintense on the T2 Weighted images. Indentation on the anterior dural theca by the postero-superior margin of L3 is noted.
There is mild forward subluxation of the L4 over the L5 vertebra. A pseudo-posterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L4-L5 facet joints show degenerative changes, right more than left with resultant lateral canal stenosis.
- 2 - scan-00008
A posterior and left far lateral disc herniation is noted at the L3-L4 level with anterior indentation of the thecal sac and left neural foraminal narrowing.
There is a posterior and bilateral far lateral disc herniations with peridiscal osteophytes at the L2-L3 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing.
The lumbar facet joints show degenerative changes.
The lumbar intervertebral discs expect for the L2-L3 disc show loss of water content.
The visualized dorsal, rest of the lumbar and sacral vertebral bodies and the iliac bones show fatty marrow changes suggestive of osteoporosis.
The visualized prevertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12-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 :
12.0 mm at L1-L2
10.0 mm at L2-L3
12.0 mm at L3-L4
8.0 mm at L4-L5
11.0 mm at L5-S1.
The MRI features are suggestive of :
1. Wedging of the L3 vertebral body with altered signal is most likely due to osteoporotic collapse with bone edema as described.
- 3 - Scan-00008
The possibility of this being a pathological fracture cannot be ruled out though less likely.
2. Mild forward subluxation of the L4 over the L5 vertebra with a pseudo-posterior disc herniation at the L4-L5 level
and facetal arthropathy, right more than left with resultant lateral canal stenosis at this level.
3. A posterior and left far lateral disc herniation at the L3-L4 level.
4. A posterior and bilateral far lateral disc herniations with peridiscal osteophytes at the L2-L3 level.
5. Mild facetal arthropathy in the lumbar region.
6. Osteoporotic changes in the rest of the visualized vertebrae and bony pelvis.