sb/hs/nl/nl

Name of the Patient : Abc Xyzti lmn / F / 92 yrs.
Referred by : Dr. Abc XyzV. Shah / Dr. Abc Xyzh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE with paresthesias.
Alleged H/O fall.

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 :

All the visualized dorso-lumbo-sacral vertebral bodies show spotty fatty marrow changes, suggesting osteoporosis.

There is anterior wedging of the D12 vertebral body without any other change in its signal intensity.

The D11-D12 intervertebral disc shows a hyperintense signal on the T2 Weighted images. Indentation on the anterior dural theca is noted by the postero-superior margin of the D12 vertebral body. A posterior disc bulge with peridiscal osteophytes is noted at the D11-D12 level.

The lumbar intervertebral discs show loss of water content.

Posteriorly herniated discs with peridiscal osteophytes are noted at the L3-L4 and L4-L5 levels, bilaterally. There is facetal and ligamentum flavum hypertrophy with canal stenosis at these levels. The exiting right L3 nerve root is impinged in the right neural foramen at the L3-L4 level.



Small, postero-central protruded discs with peridiscal osteophytes are noted at the L1-L2, L2-L3 and L5-S1 levels, with slight facetal hypertrophy at these levels. Slight facetal hypertrophy is also noted at the D10-D11 level.

The visualized pre and paravertebral soft tissues are unremarkable.

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 :

11.0 mm at L1-L2
12.0 mm at L2-L3
9.0 mm at L3-L4
13.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

1. Anterior wedging of the D12 vertebral body is most likely due to a traumatic vertebral body fracture superimposed on an osteoporotic spine (less likely to be a pathologic fracture).

2. Posteriorly herniated discs with peridiscal osteophytes at the L3-L4 and L4-L5 levels, with facetal and ligamentum flavum hypertrophy and canal stenosis. Impingement of the exiting right L3 nerve root is noted in the right neural foramen at the L3-L4 level.

3. Small, postero-central protruded discs with peridiscal osteophytes at the L1-L2, L2-L3 and L5-S1 levels with, slight facetal hypertrophy at these levels.