sb/bv/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzben lmn / F / 78 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE with numbness since 1 month.
H/O fall 2 years back.

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 partial sacralization of the L5 vertebra on the right which is as marked on the film.

There is loss of water content of the lumbar intervertebral discs.

There is Grade I spondylolisthesis of the L4 over the L5 vertebra without obvious spondylolysis.

There is central wedging of the D12 vertebral body which appears hypointense on the T1 Weighted images and heterogeneously hypointense on the T2 Weighted images. The superior and inferior cortical endplates of D12 appear intact. Mild bulge of the posterior margin of the D12 body is noted indenting the dural theca anteriorly.

Central and anterior wedging of the D10 and L1 vertebral bodies is also noted with fatty marrow changes. Fairly large posterior peridiscal osteophyte is noted at the L1-L2 and D10-D11 levels indenting the dural theca anteriorly.
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Slight central wedging of the L3 vertebral body along its inferior margin is noted with a subtle hypointense signal on T1 Weighted images which turns hyperintense on the T2 Weighted images adjacent to the inferior cortical endplates of the L3 vertebral body which may represent a compression fracture.

Posteriorly bulging discs are noted at the L5-S1, L4-L5 and L2-L3 levels indenting the dural theca anteriorly.

A posteriorly herniated disc is noted at the L3-L4 level with bilateral neural foraminal narrowing and canal stenosis.

Facetal hypertrophy is noted at the D11-D12, L4-L5 and L3-L4 levels bilaterally.

The rest of the visualized dorsal and lumbar vertebral bodies show spotty fatty changes suggesting osteoporosis.

The visualized pre and paravertebral soft tissues are unremarkable.

The lower dorsal spinal cord shows normal signal.

The conus medullaris terminates at the D12-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 :

15.0 mm at L1-L2
15.0 mm at L2-L3
12.0 mm at L3-L4
10.0 mm at L4-L5
9.0 mm at L5-S1.

Screening T1 Weighted sagittal images of the dorsal spine reveal wedged D9 vertebra with fatty marrow changes in the rest of the dorsal vertebrae as described.
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IMPRESSION :

1. Partial sacralization of the L5 vertebra on the right.

2. Grade I spondylolisthesis of the L4 over the L5 vertebra without obvious spondylolysis.

3. Wedging of the D10, D12, L1 and L3 vertebral bodies as described most likely is the sequelae of previous compression fractures superimposed on an osteoporotic spine. Altered signal in the D12 vertebral body suggests bone bruise/edema.

4. Fairly large posterior peridiscal osteophyte at the L1-L2 and D10-D11 levels.

5. Posteriorly bulging discs at the L5-S1, L4-L5 and L2-L3 levels.

6. A posteriorly herniated disc at the L3-L4 level with bilateral neural foraminal narrowing.

7. Facetal hypertrophy at the D11-D12, L4-L5 and L3-L4 levels bilaterally.

8. Lower lumbar canal stenosis.

9. Fatty marrow changes in the visualized dorsal and lumbar vertebral bodies (except for D12 and L3 vertebrae) suggests osteoporosis.