Date : 00.00.00

Name of the Patient : Abc Xyzlmn / M / 69 yrs.
Referred by : Dr. Abc Xyzaubal.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE since 2 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 scoliosis of the lumbar spine with convexity to the left with clockwise rotation of the mid-lumbar vertebrae.

There is a decrease in the height of the D12 vertebral body. This vertebra appears hypointense on the T1 Weighted images and turns heterogeneously hyperintense on the T2 Weighted images. Linear hypointensities on all the pulse sequences within it would suggest compressed trabeculae. The D12 vertebral body is wedged anteriorly and is seen to bulge posteriorly with indentation upon the cord. There appears to be a break of the superior and inferior cortical endplates of the D12 vertebra.

A postero-central disc herniation with peridiscal osteophytes is seen to indent the thecal sac at the L5-S1 level. A left postero-lateral (foraminal) disc herniation is seen to narrow the left neural foramen and impinge the exiting left L5 nerve root at this level. The left L5-S1 facet joint shows hypertrophic degenerative changes. Also seen is a left far lateral (extraforaminal) disc herniation indenting the extraforaminal portion of the exiting left L5 nerve root at this level.

A posterior disc herniation with peridiscal osteophytes, more to the right of the midline is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level. A right far lateral (extraforaminal) disc herniation is seen to indent the extraforaminal portion of the exiting right L4 nerve root at the L4-L5 level. The L4-L5 facet joints, bilaterally, show hypertrophic degenerative changes. Also seen is ligamentum flavum hypertrophy at this level.
...2/..




- 2 -


A postero-central disc herniation with peridiscal osteophytes is seen to indent the thecal sac at the L3-L4 level. A right postero-lateral (foraminal) disc herniation is seen to narrow the right neural foramen at the L3-L4 level. The right facet joint at this level shows hypertrophic degenerative changes.

The lumbar intervertebral discs show loss of water content. Anterior disc herniations are seen at the L3-L4, L4-L5 and L5-S1 levels.

Schmorls node is seen in the L2 vertebra superiorly.

The lumbar vertebral bodies show areas of fatty replacement of normal marrow suggestive of osteoporotic changes. The cervico-dorsal spine was screened with 5 mm thick T1 Weighted sagittal images and the visualized cervico-dorsal vertebral bodies show similar signal changes.

Posteriorly bulging discs are noted at the D9-D10 and D10-D11 levels.

The visualized pre and paravertebral soft tissues are unremarkable. Incidental note is made of a large extrarenal pelvis on the left side.

The conus medullaris terminates at the L1 level and the thecal sac terminates at the S2 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

13.0 mm at L2-L3

13.0 mm at L3-L4

10.0 mm at L4-L5

12.0 mm at L5-S1.
...3/..











- 3 -


IMPRESSION :

The MRI features are suggestive of :

1. Compression fracture of the D12 vertebral body superimposed upon an osteoporotic spine. The possibility of a pathologic fracture seems less likely.

2. Postero-central disc herniations with peridiscal osteophytes at the L3-L4 and L5-S1 levels.

3. A left postero-lateral (foraminal) and left far lateral (extraforaminal) disc herniation at the L5-S1 level.

4. A right postero-lateral (foraminal) disc herniation at the L3-L4 level.

5. A posterior disc herniation with peridiscal osteophytes, more to the right of the midline with bilateral hypertrophic facetal arthropathy and ligamentum flavum hypertrophy with canal stenosis at the L4-L5 level.

6. A right far lateral (extraforaminal) disc herniation at the L4-L5 level.

7. Hypertrophic facetal arthropathy on the left side at the L5-S1 level and on the right side at the L3-L4 level.