Date : 00.00.00
Name of the Patient : Abc Xyzn lmn / F / 60 yrs.
Referred by : Dr. Abc Xyzin / Dr. Abc Xyzlal.
Examination : M.R.I. of the Dorso-lumbar Spine.
CLINICAL PROFILE :
Known C/O Ca gall bladder with alleged H/O fall 2 months back.
C/O backache with pain radiating to BLE with tingling since then.
M.R.I of the dorso-lumbar 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 sacralization of the L5 vertebra and the L3 vertebral body is as marked on the film. Please correlate with plain radiographs.
There is slight loss of water content of the visualized dorso-lumbar intervertebral discs.
There is anterior wedging of the D11 vertebral body and which appears predominantly hypointense on all the pulse sequences. Ill-defined hyperintense signal on the T2 Weighted images is noted in the posterior third of the body of the D11 vertebral body. There is minimal indentation on the anterior dural theca by the postero-superior margin of the D11 vertebral body. Break in the superior cortical endplate of D11 is noted (scan 102.4). The D10-D11 and D11-D12 intervertebral discs are otherwise unremarkable. Slight hypertrophy of the D10-D11 articular facets is noted
Minimal posterior disc bulges are noted at the L1-L2, L2-L3, L3-L4 and L4-L5 levels. Bilateral far lateral (extraforaminal) disc bulges are seen at the L4-L5 level.
Slight facetal hypertrophy is also noted at the L2-L3, L3-L4 and L4-L5 levels.
Schmorls nodes are noted in the dorso-lumbar region.
Slight central wedging of the D10 vertebral body is also noted.
The rest of the visualized dorso-lumbar vertebral bodies show spotty fatty marrow changes suggesting osteoporosis. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12-L1 level.
Screening, T1 Weighted sagittal images of the cervico-dorsal region reveal fatty marrow changes involving the cervico-dorsal vertebral bodies.
1. Wedging of the D11 vertebral body with altered signal most likely represents a compression fracture superimposed on an osteoporotic spine. The possibility of this lesion representing a pathological fracture or a metastatic deposit cannot be entirely excluded in the given clinical setting.
2. Fatty marrow changes in the rest of the spinal axis suggests osteoporotic changes.
3. Sacralized L5 vertebra. Please correlate with plain radiographs.