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sb/bv/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzen lmn / F / 65 yrs.
Referred by : Dr. Abc Xyzcha.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE and inability to walk since 8-9 months.
Alleged H/O fall prior to this.

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 near complete collapse of the L1 vertebral body with retropulsion of the posterior body of L1 and resultant thecal sac compression at the L1 vertebral level. The anterior portion of the visualized L1 vertebral body shows a hypointense signal on all pulse sequences. Lateral splaying of the body of L1 is noted. The posterior portion of L1 shows fat signal characteristics on all the pulse sequences. The D12-L1 and L1-L2 intervertebral discs show loss of water content and as do the rest of the lumbar intervertebral discs. A kyphus is noted at the L1 level. The lower dorsal spinal cord shows normal signal intensity.

The L5 vertebra is sacralized.

A posteriorly bulging disc is noted at the L4-L5 level.
There is facetal and ligamentum flavum hypertrophy with resultant canal stenosis.

A left postero-lateral disc bulge is noted L3-L4 level with slight left neural foraminal narrowing.
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The facet joints in the lumbar region appear slightly hypertrophied.

The pedicles of the lower lumbar vertebrae appear congenitally short in their antero-posterior dimensions.

Fatty marrow changes are noted in the D12 and L2 vertebral bodies.

The rest of the lumbar vertebral bodies reveal spotty marrow changes. The visualized pre and paravertebral soft tissues are unremarkable.

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

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

8.0 mm at L1-L2
11.0 mm at L2-L3
10.0 mm at L3-L4
11.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. Sacralized L5 vertebra.

2. Near complete collapse of the L1 vertebral body with retropulsion and thecal sac compression at that level is most likely post-traumatic in etiology.

The possibility of this fracture superimposed upon a pathology seems less likely.

3. A posteriorly bulging disc at the L4-L5 level with facetal and ligamentum flavum hypertrophy with resultant canal stenosis at this level.

4. Slight facetal hypertrophy in the lumbar region.

5. Congenitally short pedicles of the lower lumbar vertebrae in their antero-posterior dimensions.

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