ke/sb/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzai Niklmn / F / 80 yrs.
Referred by : Dr. Abc Xyzasde.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

H/O fall 8 days back with backache and weakness of the RUE and RLE since then.

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 anterior wedging of the D11, L1, L2 and L3 vertebral bodies. The lower dorsal and lumbar vertebrae show fatty changes, suggestive of osteoporosis.

There is slight central wedging of the D12 vertebral body which shows hypointense areas on the T1 Weighted images. These are seen to turn heterogeneously hyperintense on the T2 Weighted images and would represent bone edema, the sequelae of a compression fracture.

Small posterior disc bulges are seen at the L3-L4 and L4-L5 levels with anterior indentation of the thecal sac. Left far lateral disc bulge is noted at the L4-L5 level.

Small posterior disc protrusions are seen at the D11-D12, D12-L1 and L1-L2 levels. The upper lumbar intervertebral discs show loss of water content.

The lumbar facet joints show degenerative changes.


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 :

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

Incidentally noted is a gallsteone.

IMPRESSION :

The MRI features are suggestive of :

1. Altered signal of the lower dorsal and lumbar vertebrae suggests osteoporosis. Anterior wedging of the D11, L1, L2 and L3 vertebral bodies may be the sequelae of osteoporotic fractures.

2. Slight central wedging of the D12 vertebral body with altered signal would represent compression fracture, with bone edema, the sequalae of previous trauma, superimposed on an osteoporotic spine.

3. Small posterior disc bulges at the L3-L4 and L4-L5 levels and a left far lateral disc bulge at the L4-L5 level.

4. Small posterior disc protrusions at the D11-D12, D12-L1 and L1-L2 levels.

5. Degenerative changes of the lumbar facet joints.

6. Gallstone in the visualized gallbladder.