Date : 00.00.00
Name of the Patient : Abc Xyzbi Islmn / F / 55 yrs.
Referred by : Dr. Abc Xyzauhan.
Examination : M.R.I. of the Dorso-lumbar Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE with paresthesias.
H/O bone TB several years ago. Received AKT.
M.R.I of the dorso-lumbar 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 is scoliotic deformity of the dorso-lumbar spine.
Slight right lateral wedging of the L4 vertebral body is noted. The L3-L4 intervertebral disc is not well-identified.
The rest of the lumbar intervertebral discs show slight loss of water content.
A small, posteriorly bulging disc with peridiscal osteophytes is noted at the L4-L5 level indenting the dural theca anteriorly.
Small posterior peridiscal osteophytes are noted at the L3-L4 and L2-L3 levels.
A hypointense signal on all the pulse sequences is noted in the right half of the L4 vertebral body may represent sclerotic changes.
Slight facetal hypertrophy is noted at the L3-L4, L4-L5 and L5-S1 levels with slight ligamentum flavum hypertrophy at the L4-L5 level.
The L3 and L4 vertebral bodies show spotty fatty marrow changes.
The rest of the visualized dorso-lumbar vertebral bodies reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The visualized lower dorsal spinal cord reveals normal signal intensity.
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 :
18.0 mm at L1-L2
15.0 mm at L2-L3
18.0 mm at L3-L4
15.0 mm at L4-L5
13.0 mm at L5-S1.
1. Slight right lateral wedging of the L4 vertebral body with fatty marrow changes in the L3 and L4 vertebral bodies, and sclerotic changes in the L4 vertebral body and reduction in height of the L3-L4 intervertebral disc is most likely the sequelae of previous tuberculous osteitis.
2. A small, posteriorly bulging disc with peridiscal osteophytes at the L4-L5 level.
3. Small posterior peridiscal osteophytes at the L3-L4 and L2-L3 levels.
4. Slight facetal hypertrophy at the L3-L4, L4-L5 and L5-S1 levels with slight ligamentum flavum hypertrophy at the L4-L5 level.