sb/ke/nl/rg.
Name of the Patient : Abc Xyzn lmn / F / 77 yrs.
Referred by : Dr. Abc Xyz. Kapadia.
Examination : M.R.I. - Dorso-lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with tingling in the LLE.
EXAMINATION :
M.R.I of the dorso-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 loss of water content of the visualized dorso-lumbo-sacral intervertebral discs.
There is slight anterior wedging of the D12 vertebral body. Herniation of the D11-D12 disc into the body of the D12 is noted.
There is central wedging of the L3 and L4 vertebral bodies. The L2 and L3 vertebral bodies adjacent to the L2-L3 disc shows a hyperintense signal on the T2 Weighted images (iso to slightly hypointense on the T1 Weighted images) which most likely suggest Type I degenerative marrow changes. Herniation of the L2-L3 intervertebral disc into the body of L3 and of the L4-L5 intervertebral disc into the body of L4 is noted.
A posterior disc bulge is noted at the L5-S1 level.
Posteriorly bulging disc with peridiscal osteophytes is noted at the L4-L5 level.
Facetal and ligamentum flavum hypertrophy is noted at the L4-L5 level.
Small posterior disc bulges with peridiscal osteophytes are noted at the L2-L3, D11-D12 and D12-L1 levels.
Slight facetal hypertrophy is noted at the L2-L3 and L5-S1 levels.
The visualized dorso-lumbo-sacral vertebral bodies show preponderance of hematopoeitic marrow. The visualized pre and paravertebral soft tissues are unremarkable.
The lower dorsal spinal cord shows normal signal intensity. There is no cord compression.
The conus medullaris terminates at the L1-L2 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 :
15.0 mm at L1-L2
15.0 mm at L2-L3
15.0 mm at L3-L4
11.0 mm at L4-L5
12.0 mm at L5-S1.
Incidentally noted is hepatosplenomegaly.
The left kidney is displaced anteriorly by the enlarged spleen.
IMPRESSION :
1. Anterior wedging of the D12 vertebral body and central wedging of the L3 and L4 vertebral bodies is most likely post-traumatic in etiology
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2. Posteriorly bulging disc with peridiscal osteophytes, facetal and ligamentum flavum hypertrophy at the L4-L5 level.
3. Small posterior disc bulges with peridiscal osteophytes at the L2-L3, D11-D12 and D12-L1 levels.
4. Slight facetal hypertrophy at the L2-L3 and L5-S1 levels.
5. Hepatosplenomegaly with preponderance of the hematopoetic marrow in the visualized dorso-lumbo-sacral vertebrae. A hematopoeitic disorder should be ruled out.