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hs/sb/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzlmn / F / 80 yrs.
Referred by : Dr. Abc Xyzngsarkar / Dr. Abc Xyz.
Examination : M.R.I. of the Dorso-lumbar Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to LLE with tingling.

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 evidence of collapse of the D12 vertebral body with anterior wedging. A large osteophyte is seen to arise from the posterior superior aspect of the D12 vertebral body with resultant indentation on the thecal sac. Anterior peridiscal osteophytes are noted at the D11-D12 level. The superior cortical endplate of the D12 vertebra is irregularly defined.

There is mild retroplacement of the L4 vertebra over the L5 vertebra.

A posterior disc herniation with peridiscal osteophytes is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level. Also seen is facetal hypertrophy at this level. cste

Posterior and far lateral extraforaminal disc bulges are noted at the L5-S1 level. The L5-S1 facet joints bilaterally show severe hypertrophic degenerative changes.



Mild posterior disc bulges are noted at the L2-L3 and L3-L4 levels.

There is mild ligamentum flavum hypertrophy at the L5 and S1 levels.

The visualized dorso-lumbar vertebral bodies show areas of fatty replacement of normal marrow suggestive of osteoporosis.

There is atrophy of the paraspinal muscles in the dorso-lumbar region.

The visualized dorso-lumbar intervertebral discs show loss of water content.

The dorsal spine was screened with 4 mm thick T1 Weighted and T2 Weighted sagittal images. Facetal hypertrophy is seen at the D9-D10 level. The visualized dorsal spinal cord and conus medullaris show normal signal intensity.

The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12-L1 level and the thecal sac terminates at the S1-S2 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

11.0 mm at D10-D11
14.0 mm at D11-D12
16.0 mm at D12-L1
13.0 mm at L1-L2
11.0 mm at L2-L3
14.0 mm at L3-L4
13.0 mm at L4-L5
11.0 mm at L5-S1.
..3/.






- 3 - Scan-00007


IMPRESSION :

The MRI features are suggestive of

1. Collapse of the D12 vertebral body with anterior wedging. This most likely represents a compression fracture superimposed upon an osteoporotic spine (less likely to be superimposed upon a pathologic process). A postero-superior osteophyte is noted at D12.

2. A posterior disc herniation with peridiscal osteophytes, facetal hypertrophy and canal stenosis at the L4-L5 level.

3. Severe hypertrophic facetal arthropathy at the L5-S1 level.

4. Facetal hypertrophy at the D9-D10 level.

As compared to the previous MRI dated 00.00.0000, there is slight increase in the degree of the disc herniation at the L4-L5 level. The wedging of the D12 body is a new finding on the present study.


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