Date : 00.00.00
Name of the Patient : Abc Xyz S. Mlmn / F / 50 yrs.
Referred by : Dr. Abc Xyz
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 2-3 months.
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.
The lumbar intervertebral discs show loss of water content with reduction in height of the D12-L1, L1-L2 and L2-L3 intervertebral discs.
There is slight retrolisthesis of the L2 over the L3 vertebral body.
Fatty changes are noted within the L1, L2 and L3 vertebral bodies, suggestive of healing of the previously identified infective process. Schmorls node is seen in the superior aspect of the L2 vertebra.
The L2-L3, L3-L4, L4-L5 and L5-S1 facet joints show degenerative changes.
A right far lateral disc bulge is identified at the L2-L3 level.
The L4 and L5 vertebral bodies reveal normal signal intensity. The L1-L2 facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
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 :
15.0 mm at L1-L2
16.0 mm at L2-L3
19.0 mm at L3-L4
19.0 mm at L4-L5
20.0 mm at L5-S1.
1. Slight retrolisthesis of the L2 over the L3 vertebral body.
2. Fatty changes within the L1, L2 and L3 vertebral bodies, suggests healing of the previously identified infection.
3. Hypertrophy of the L2-L3, L3-L4, L4-L5 and L5-S1 facet joints.
As compared to the previous MRI (study no:00002) dated 00.00.00, there is now fatty change in the L1, L2 and L3 vertebral bodies suggestive of healing and the right paravertebral abscess is no longer visualized.