Date : 00.00.00
Name of the Patient : Abc Xyzedali Nazlmn / M / 45 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
Alleged H/O being hit by a heavy object on the back 15-20 days back with pain in the back radiating to the LLE since then.
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 loss of water content of the L2-L3 and L4-L5
There is anterior wedging of the L1 vertebral body with break in the superior cortex anteriorly. Hypointense areas on the T1 Weighted images are seen to replace the normal marrow of the L1 vertebra. These are seen to turn hyperintense on the T2 Weighted images and would represent edema/bruise, in the given clinical setting.
There is a left paracentral disc herniation at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing at this level, more marked on the left side. The facet joints appear hypertrophied.
A small posterior disc herniation is seen at the L2-L3 level.
Posterior disc bulges are identified at the L3-L4 and L5-S1 levels. A left far lateral disc bulge is seen at the L1-L2 level.
The rest of the lumbar vertebral bodies reveal normal signal intensity. The remaining 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 :
16.0 mm at L1-L2
13.0 mm at L2-L3
14.0 mm at L3-L4
12.0 mm at L4-L5
13.0 mm at L5-S1.
1. Altered signal in the L1 vertebral body with anterior wedging and break in the superior cortex suggests a fracture with bone edema/bruise, in the given clinical setting.
2. A left paracentral disc herniation at the L4-L5 level with bilateral neural foraminal narrowing, facetal hypertrophy and tight lumbar canal.
3. A small posterior disc herniation at the L2-L3 level.