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Date : 00.00.00

Name of the Patient : Abc XyzAhmed G. Mlmn / M / 30 yrs.
Referred by : Dr. Abc Xyzrankar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

H/O vehicular accident 10 days ago with injury to the RLE and back.
C/O weakness of BLE with bladder involvement since then.

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.

6 mm thick T1 Weighted coronal images.

OBSERVATION :

There is lateral subluxation of the L2 vertebra to the right, in relation to the L3 vertebral body. The L3 vertebral body shows an ill-defined, hyperintense signal on the T2 Weighted images (hypointense on the T1 Weighted images) which suggests bone bruise, in the given clinical setting. Break in the superior cortical endplate of L3 is noted. The L2-L3 intervertebral disc shows a hyperintense signal on the T2 Weighted images which suggests a traumatic rupture of the disc, in the given clinical setting. There is also fracture of the posterior elements of the L3 vertebra with entrapment of the exiting L2 nerve root on the left in the left neural foramen at the L2-L3 level and of the L3 nerve root on the right in the right neural foramen at the L3-L4 level.



There is seen a well-marginated, hyperintense lesion on the T1 Weighted images in the right paravertebral region (medial to the right psoas muscle) extending over L3 to L5 vertebral levels. This lesion remains hyperintense on the T2 Weighted images. Similar signal intensity lesion is noted in the posterior paraspinal muscles and in the left posterior paraspinal region at the L3 vertebral level. Extension of the lesion into the left postero-lateral epidural space at L3 and anterior and right lateral epidural space at L2 vertebral level is noted with thecal sac compression. The roots are not very well-identified at this level. There is also a suspicion of haemorrhage/paramagnetic substance deposition in the conus cauda region (scan 106.10).

There is disruption of the facet joints at the L2-L3 level bilaterally.

Soft tissue injury/edema is noted in the subcutaneous tissues of the back.

The rest of the lumbar vertebral bodies and the intervertebral discs reveal normal signal intensity.

The conus medullaris terminates at the L1-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 :

17.0 mm at L1-L2
15.0 mm at L3-L4
14.0 mm at L4-L5
13.0 mm at L5-S1.

IMPRESSION :

1. Lateral subluxation of the L2 vertebra to the right, in relation to the L3 vertebral body.
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- 3 - Scan-00005


2. Altered signal in the L3 vertebral body represents bone bruise/edema. Fracture of the posterior elements of the L3 is noted with traumatic rupture of the L2-L3 intervertebral disc.

3. Entrapment of the exiting L2 nerve root on the left and of the L3 nerve root on the right in their respective neural foramina.

4. Altered signal intensity lesion in the right paravertebral region, posterior paraspinal muscles and in the epidural space at the L2 and L3 vertebral levels as described most likely represents a hematoma in the given clinical setting.

5. Traumatic disruption of the facet joints at the L2-L3 level bilaterally.


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