ke/hs/nl/rg.
Date : 00.00.00
Name of the Patient : Abc Xyz Manjrlmn / F / 25 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Dorso-lumbar Spine.
CLINICAL PROFILE :
H/O fever with headaches, vomiting, diplopia and pain with paresthesias in BLE since 1 month.
C/O TBM on AKT since 15 days.
EXAMINATION :
M.R.I of the dorso-lumbar spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and T2 Weighted axial images.
OBSERVATION :
The D9 vertebra appears to be as marked on the film and there is probable sacralizaton of the L5 vertebra. Please correlate with plain radiographs.
There is a posterior disc herniation at the D12-L1 level with anterior indentation of the thecal sac. Slight superior
migration of the disc is noted.
A small posterior disc herniation with posterior peridiscal osteophytes is noted at the D10-D11 level. The D10-D11 and D12-L1 intervertebral discs show loss of water content.
The visualized dorso-lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The visualized dorsal spinal cord reveals normal signal intensity.
..2/.
The conus medullaris terminates at the L1 level and the thecal sac terminates at the S1 level. There is probable sacralization of the L5 vertebra.
The cervico-dorsal spine was screened with 4 mm thick T2 Weighted sagittal images and does not reveal any diagnostic feature of note.
IMPRESSION :
1. A posterior disc herniation at the D12-L1 level with slight superior migration of the disc.
2. A small posterior disc herniation with posterior peridiscal osteophytes at the D10-D11 level.
3. Probable sacralization of the L5 vertebra. Please correlate with plain radiographs.