Date : 00.00.00
Name of the Patient : Abc XyzR. Plmn / M / 75 yrs.
Referred by : Dr. Abc Xyzatil / Dr. Abc Xyzvadekar
Examination : M.R.I. of the Dorso-lumbar Spine.
CLINICAL PROFILE :
C/O backache since 2 months.
H/O fall prior to this.
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 anterior wedging of the D12 vertebral body. Hypointense signal is noted on the T1 Weighted images within this vertebral body anteriorly and superiorly. This area is seen to turn hyperintense on the T2 Weighted images and would represent edema. Some areas are seen to remain hypointense on all the pulse sequences and would represent compressed trabeculae. There is a break in the superior cortical endplate.
There is no pre/paravertebral extension of the disease process.
A CSF signal intensity lesion is noted on all the pulse sequences in the right neural foramen at the D12-L1 level and may represent a meningeal cyst. A similar smaller lesion is noted in the left neural foramen, at the D12-L1 level and on the right side at the D11-D12 level.
A diffuse posterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. There is ligamentum flavum and facetal hypertrophy with resultant tight lumbar canal.
Left far lateral disc bulge is seen at the L3-L4 level. A small posterior disc bulge is noted at the L5-S1 level.
The lower lumbar intervertebral discs show loss of water content.
There is anterior wedging of the D6, D7 and D8 vertebral bodies without any change in signal intensity.
The L5-S1 facet joint also shows degenerative changes.
The lumbar vertebral bodies show spotty fatty changes suggesting osteoporosis. 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.
Incidental note is made of simple cortical cysts in both kidneys, large ones in the right kidney.
The MRI features are suggestive of :
1. Anterior wedging of the D12 vertebral body with altered signal is most likely post-traumatic in etiology superimposed upon an osteoporotic spine.
2. A diffuse posterior disc herniation at the L4-L5 level.
3. Facetal arthropathy at the L4-L5 and L5-S1 levels with tight canal at the L4-L5 level.