sb/ke/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzen lmn / F / 72 yrs.
Referred by : Dr. Abc Xyzain.
Examination : M.R.I. of the Dorso-lumbar Spine.

CLINICAL PROFILE :

C/O backache with weakness of BLE since 2-3 months.
H/O Pulmonary kochs. On AKT since 4 months.

EXAMINATION :

M.R.I of the dorso-lumbar 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 loss of water content of the dorso-lumbar intervertebral discs.

There is an ill-defined, hypointense signal on the T1 Weighted images in the left pedicle, transverse process and superior articular process on the left of the L5 vertebra and in the left half of the sacrum adjcent to the left sacro-iliac joint. This lesion appears hyperintense on the T2 Weighted images.

Effusion is noted in the sacro-iliac joint on either side with suspicious irregularity of the margins of the sacro-iliac joints.

A small postero-central protruded disc is noted at the L5-S1 level. Slight ligamentum flavum hypertrophy is noted at the L4-L5 and L5-S1 levels.

A posteriorly herniated disc with peridiscal osteophyte is seen at the L4-L5 level with bilateral neural foraminal narrowing.


A small poster-central protruded disc with peridiscal osteophytes is noted at the D12-L1 level.

Focal fatty marrow changes are noted in the lumbar vertebrae.

The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The lower dorsal spinal cord reveals normal signal intensity. There is no cord compression.

The conus medullaris terminates at the L1-L2 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
15.0 mm at L2-L3
12.0 mm at L3-L4
12.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. Altered signal in the left pedicle, transverse process and and superior articular process of L5 vertebra is not specific for a single etiology. Osteitis is a likely possibility in view of the H/O Pulmonary tuberculosis. The possibility of a neoplasm or a degenerative etiology seems less likely. Similar signal change is noted in the sacrum on the left.

2. Effusion in the sacro-iliac joint on either side is of ? etiology ?? degenerative.

3. A small postero-central protruded disc at the L5-S1 level
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4. A posteriorly herniated disc with peridiscal osteophyte at the L4-L5 level with bilateral neural foraminal narrowing.

5. A small poster-central protruded disc with peridiscal osteophytes at the D12-L1 level.

6. Slight ligamentum flavum hypertrophy at L4-L5 and L5-S1 levels.