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hs/sb/rg.
Date : 00.00.00

Name of the Patient : Abclmn / F / 68 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

H/O fall on the back 20 days ago with severe pain in the low back.

EXAMINATION :

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.

OBSERVATION :

There is slight forward listhesis of the L4 over the L5 vertebrae.

There is anterior wedging of the L1 vertebral body. A fracture line is seen to course through the postero-superior aspect of this vertebral body. Linear hypointensities on all the pulse sequences are seen within it and may represent compressed trabeculae. Hypointense areas on the T1 Weighted images which turn hyperintense on the T2 Weighted images are also seen, which may represent bone edema.

Posterior disc bulges are seen at the L1-L2, L2-L3, L3-L4, L4-L5 and L5-S1 levels. Small posterior peridiscal osteophytes are noted at the L1-L2 and L2-L3 levels.

A small left postero-lateral (foraminal) disc herniation is seen to narrow the left neural foramen at the L4-L5 level. The left L4-L5 facet joint shows hypertrophic degenerative changes.


Far lateral (extraforaminal) disc herniations are seen at the L3-L4 level. Anterior disc herniations with peridiscal osteophytes are noted at the L2-L3 and L3-L4 levels.

The L3-L4 and L5-S1 facet joints show mild degenerative changes.

The lumbar intervertebral discs show loss of water content.

The rest of the lumbar vertebral bodies show areas of fatty replacement of normal marrow.

A Tarlovs perineural cyst is seen within the spinal canal on the right side at the S2 vertebral level.

The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1 level and the thecal sac terminates at the S2 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

18.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
13.0 mm at L4-L5
13.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. Compressed fracture of the L1 vertebra (less likely to be superimposed upon a pathology).

2. Posterior disc bulges at the L1-L2, L2-L3, L3-L4, L4-L5 and L5-S1 levels.

3. Small posterior peridiscal osteophytes at the L1-L2 and L2-L3 levels.
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4. A small left postero-lateral (foraminal) disc herniation at the L4-L5 level.

5. Hypertrophic facetal arthropathy on the left side at the L4-L5 level.

6. Mild facetal arthropathy at the L3-L4 and L5-S1 levels.






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