Name of the Patient : Abc Xyzal lmn / M / 32 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
Alleged H/O fall from a train on 00.00.0000 with paraplegia and incontinence of urine since then.
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 sacrum and S. I. joints were scanned with 5 mm thick T1 Weighted axial images and 5 mm thick STIR coronal images.
There is loss of normal lumbar lordosis.
A small posterior disc bulge is noted at the L4-L5 level.
The facet joints at the L4-L5 and L5-S1 levels show degenerative changes bilaterally.
There is evidence of a fracture of the sacrum on the right, just lateral to the sacral foramina. There is a resultant ill-defined, hyperintense signal on the STIR images in the right half of the sacrum. Soft tissue is noted in the presacral space and along the exiting nerve roots in the sacral region on the right which may represent soft tissue contusion/hematoma. There is probable encasement of the roots of the sacral plexus over these levels. This soft tissue is seen to extend lateral to the right psoas muscle upto the L2-L3 disc space and also, probably along the left psoas muscle upto the L3-L4 disc space. Ill-defined
hyperintense signal on the STIR images in the left gluteal region may represent a soft tissue contusion. Probable involvement of the S3 and S4 vertebral bodies is noted. There is no definite evidence of extension of the fracture line upto the right sacro-iliac joint per se.
The lumbar vertebral bodies and the intervertebral discs reveal normal signal intensity. The remaining facet joints 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 :
17.0 mm at L1-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
15.0 mm at L4-L5
12.0 mm at L5-S1.
1. A fracture of the sacrum on the right, just lateral to the sacral foramina with altered signal in the right half of the sacrum suggesting bone bruise/edema.
2. Soft tissue in the presacral space, along the exiting sacral nerve roots on the right with probable encasement and along the psoas muscles as described would represent soft tissue contusion/hematoma, in the given clinical setting. Similar lesion is noted in the left gluteal region.
3. Bone bruise/fracture involving the S3 and S4 vertebral bodies.
4. Small posterior disc bulge at the L4-L5 level with degenerative changes of the L4-L5 and L5-S1 facet joints.