Date : 00.00.00
Name of the Patient : Abc Xyzal O. Kachlmn / M / 74 yrs.
Referred by : Dr. Abc Xyzaria / Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 4-5 days.
Alleged H/O fall prior to this.
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 appears to be sacralization of the L5 vertebra and it is as marked on the film. Please correlate with plain radiographs.
There is anterior wedging of the L2 vertebral body. Few hypointense areas on the T1 Weighted images which turn hyperintense on the T2 Weighted images are seen within this vertebral body, superiorly and may represent bone edema. Linear hypointensities on all the pulse sequences within this vertebral body along its superior cortical endplate may represent compressed trabeculae. Its superior cortical endplate shows a large Schmorls node.
A right paracentral disc herniation is seen to indent the traversing right L5 nerve root at the L4-L5 level. There is slight inferior migration of the disc portion.
A posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L3-L4 level. A posterior disc bulge with neural foraminal narrowing is seen bilaterally at the L2-L3 level. Posterior peridiscal osteophytes are noted at the L2-L3, L3-L4 and L4-L5 levels.
- 2 - Scan-00009
The lumbar facet joints show mild degenerative changes. Ligamentum flavum hypertrophy is noted at the L3-L4 and L4-L5 levels. The lumbar intervertebral discs show loss of water content.
Bilateral far lateral (extraforaminal) disc bulges are seen at the L2-L3, L3-L4 and L4-L5 levels.
The D11-D12 intervertebral disc is hypointense on all the pulse sequences and would suggest calcium/vacuum phenomena.
The rest of the lumbar vertebral bodies reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12-L1 level and thecal sac terminates at S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
19.0 mm at L1-L2
16.0 mm at L2-L3
14.0 mm at L3-L4
12.0 mm at L4-L5
9.0 mm at L5-S1.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebra.
2. Anterior wedging of the L2 vertebral body with signal change as described most likely represents a compression fracture.
3. A right paracentral disc herniation with inferior migration of the disc portion and indentation upon the traversing right L5 nerve root at the L4-L5 level.
- 3 - Scan-00009
4. A posterior disc herniation at the L3-L4 level.
5. Posterior peridiscal osteophytes at the L2-L3, L3-L4 and L4-L5 levels.
5. Mild facetal arthropathy in the lumbar region.
6. Ligamentum flavum hypertrophy at the L3-L4 and L4-L5 levels.