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Date : 00.00.00

Name of the Patient : Abc Xyzlal V. Sanlmn / M / 68 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

Alleged H/O fall on 00.00.00.
C/O backache 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.

OBSERVATION :

There is loss of water content of the lumbar intervertebral discs.

There is central and anterior wedging of the L1 vertebral body which is minimally retroplused. The L1 vertebral body appears hypointense on the T1 Weighted images and hyperintense on the T2 Weighted images. There is a suspicious break in the superior cortical endplate of the L1 vertebral body with herniation of the L1-L2 disc into the L1 body.

Small posterior disc bulges are noted at the L3-L4, L4-L5 and L5-S1 levels and a small, postero-central protruded disc with peridiscal osteophytes is noted at the L1-L2 level.

Facetal hypertrophy is noted at the L4-L5 and L5-S1 levels bilaterally with facetal degeneration at the L5-S1 level on the right.
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Anterior peridiscal osteophytes are seen at the D12-L1 and L1-L2 levels.

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 :

13.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
12.0 mm at L4-L5
12.0 mm at L5-S1.

IMPRESSION :

1. Central and anterior wedging of the L1 vertebral body
with altered signal is not specific for a single etiology. This most likely is post-traumatic in etiology, in the given clinical setting.

The possibility of an infective or neoplastic etiology is less likely.

2. Small posterior disc bulges at the L3-L4, L4-L5 and L5-S1 levels.

3. A small, postero-central protruded disc with peridiscal osteophytes at the L1-L2 level.

3. Facetal hypertrophy at the L4-L5 and L5-S1 levels bilaterally with facetal degeneration at the L5-S1 level on the right.
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