ke/hs/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzddas Panlmn / M / 84 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE with tingling since 2 months.
Alleged H/O fall prior to this.
H/O Pulmonary Kochs 1 year back. Received AKT for 3 months.

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 central wedging of the L1 vertebral body. There is replacement of the normal marrow of the L1 vertebral body by hypointense areas on the T1 Weighted images. These are seen to turn heterogeneously hyperintense on the T2 Weighted images. The pedicles of this vertebra are also involved. There is bulging of the body into the pre and paravertebral soft tissues. Anterior epidural extension is also noted.

There are diffuse posterior disc herniations at the L3-L4, L4-L5 and L5-S1 levels with bilateral far lateral disc bulges. The facet joints at these levels show degenerative changes with bilateral neural foraminal narrowing with a resultant tight canal.






A left postero-lateral disc herniation is seen at the L2-L3 level with left neural foraminal narrowing. Bilateral far lateral (extraforaminal) disc bulges are seen at this level.

Anterior disc herniations are noted over the L1-L2 to L4-L5 levels. Schmorls nodes are noted at the inferior aspect of the L3 vertebral body and at the superior aspect of the L2 vertebral body. The lumbar intervertebral discs except for the L3-L4 show loss of water content.

Diffuse fatty changes are seen in the lower dorsal and lumbar vertebral bodies.

The conus medullaris terminates at the D12 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 :

16.0 mm at L1-L2
15.0 mm at L2-L3
14.0 mm at L3-L4
10.0 mm at L4-L5
11.0 mm at L5-S1.

The dorsal spine was screened with 5 mm thick T2 Weighted sagittal images and which does not reveal any diagnostic feature of note.

Incidental note is made of a cortical cyst in the upper pole of the left kidney.
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IMPRESSION :

1. Central wedging of the L1 vertebral body with altered signal is probably the sequelae of trauma (? superimposed on an osteoporotic spine).

The possibility of a neoplastic/infective process cannot be ruled out (pathologic process).

2. Diffuse posterior disc herniations at the L3-L4, L4-L5 and L5-S1 levels with facetal arthropathy with a resultant tight canal.