Date : 00.00.00
Name of the Patient : Abc Xyz Hlmn / F / 32 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias. ? ankylosing spondylitis.
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.
6 mm thick T1 Weighted coronal images.
The L5-S1 intervertebral disc shows a hyperintense signal on all the pulse sequences which may suggest discal calcification. A small posterior and bilateral far lateral disc bulge is noted at the L5-S1 level.
The facet joints in the lumbar region, more so at the L3-L4, L4-L5 and L5-S1 levels, appear hypertrophied. The facet joint space is not well visualized and the facets are probably ankylosed.
The visualized sacro-iliac joint space, anteriorly is also not well-defined, with probable ankylosis of the sacro-iliac joints.
Focal fatty marrow changes are noted in the visualized dorso-lumbo-sacral vertebrae and the iliac bones. The remaining intervertebral discs show normal signal intensity.
The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L2 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 :
21.0 mm at L1-L2
21.0 mm at L2-L3
22.0 mm at L3-L4
15.0 mm at L4-L5
12.0 mm at L5-S1.
1. Altered signal in the L5-S1 disc most likely suggests a calcified disc.
2. Facetal hypertrophy in the lumbar region, as described, with probable ankylosis of the facet joints may suggest ankylosing spondylitis.
3. Ankylosis of the sacro-iliac joints, anteriorly.
4. Fatty marrow changes in the visualized vertebrae, may suggest osteoporosis.