sb/bv/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyztala Ralmn / F / 63 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE since 6 months which has increased since 2 1/2 months.
H/O right Ca breast (infiltrating duct carcinoma) for which patient was operated 1 year back. Received 25 sittings of radiotherapy.

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.

The dorsal spine was screened with 5 mm thick T1 Weighted sagittal and coronal images.

OBSERVATION :

The L5 vertebra is sacralized.

There is slight central wedging of the L1 vertebral body. The L1 vertebra appears hypointense on the T1 Weighted images and heterogeneously hyperintense on the T2 Weighted images. Slight bulge of the posterior margin of the L1 vertebral body is noted. The L5, S2, S3 and S4 segments also show focal altered signal as described above.

Small posterior disc bulge is seen at the L4-L5 level.
Scan-00002


Small postero-central and left postero-lateral disc herniation is noted at the L3-L4 level.

A right far lateral (extraforaminal) disc herniation is seen at the L2-L3 level indenting the extraforaminal segment of the right L2 nerve root.

Slight facetal hypertrophy is noted in the lumbar region.

The rest of the visualized lumbar vertebral bodies reveal normal signal intensity. The lumbar intervertebral discs except the L5-S1 disc show slight loss of water content.

The visualized pre and paravertebral soft tissues 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 :

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

Screening images of the dorsal spine reveal a Schmorls node along the superior margin of the D9 vertebral body.

Changes in the pelvic bones are described in the study of the pelvis.

IMPRESSION :

1. Sacralized L5 vertebra.
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2. Altered signal in the L1, L5, S2, S3 and S4 vertebral segments as described most likely represent metastases in a known C/O Ca breast.

3. Small posterior disc bulge at the L4-L5 level.

4. Small postero-central and left postero-lateral disc herniation at the L3-L4 level.

5. A right far lateral (extraforaminal) disc herniation at the L2-L3 level indenting the extraforaminal segment of the right L2 nerve root.

6. Slight facetal hypertrophy in the lumbar region.