Date : 00.00.00
Name of the Patient : Abc Xyz. Wanklmn / F / 83 yrs.
Referred by : Dr. Abc XyzV. Shah
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE since 2 months.
Alleged H/O fall in July 0000.
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.
There is wedging of the L1 vertebral body which shows hypointense areas on the T1 Weighted images in its inferior half. These are iso to hypointense to normal marrow on the T2 Weighted images. There is slight bulging of the vertebral body anteriorly and laterally. A hypointense signal on all the pulse sequences within the L1 body, antero-inferiorly may represent vacuum phenomena.
Small posterior disc protrusions are seen at the L5-S1, L4-L5, L1-L2 and D12-L1 levels. The lumbar intervertebral discs show loss of water content.
The lumbar vertebral bodies show fatty changes of their marrow. The facet joints at the L4-L5 and L5-S1 levels appear hypertrophied. Minimal soft tissue is noted in the pre and paravertebral regions at the L1 vertebral level.
The conus medullaris terminates at the L1 level and the thecal sac terminates at the S1 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
17.0 mm at L2-L3
17.0 mm at L3-L4
14.0 mm at L4-L5
13.0 mm at L5-S1.
Incidentally noted is a hypoplastic left kidney and a 2.8 cms diameter sized right suprarenal lesion which needs to be further evaluated.
1. Wedging of the L1 vertebral body with altered signal represents traumatic compression superimposed upon an osteoporotic spine.
The possibility of this being due an infective/ neoplastic process seems less likely.
2. Small posterior disc protrusions at the L5-S1, L4-L5, L1-L2 and D12-L1 levels.
3. Facetal hypertrophy at the L4-L5 and L5-S1 levels.
4. Hypoplastic left kidney.
5. Right suprarenal lesion needs to be further evaluated.