sb/hs/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzakant Jalmn / M / 17 yrs.
Referred by : Dr. Abc Xyzrankar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

Alleged H/O fall from a height on 00.00.00 with weakness of BLE.

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 :

The L5 vertebral body is as marked on the film. Please correlate with plain radiographs.

There is evidence of a burst fracture of the L3 vertebral body with retropulsion of a fractured fragment compressing the thecal sac at that level. There is a break of the superior and inferior cortical endplates of the L3 vertebra with the L2-L3 and L3-L4 intervertebral discs appearing hyperintense on the T2 Weighted images suggesting ruptured discs. The L3 vertebral body and upper half of the L4 vertebral body appear hypointense on the T1 Weighted images and hyperintense on the T2 Weighted images, which suggests bone bruise. Fracture of the laminae of the L3 vertebra is also noted.

Posteriorly bulging discs are noted at the L3-L4 and L4-L5 levels.

Ill-defined, hyperintense signal on the T2 Weighted images is noted in the paravertebral soft tissues bilaterally in the lumabr region may suggest soft tissue injury. Probably minimal epidural and intradural hemorrhage is also noted in the lumbar region.
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Mild facetal hypertrophy is seen at the L2-L3, L3-L4 and L4-L5 levels.

The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints are unremarkable.

The conus medullaris terminates at the 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 :

17.0 mm at L1-L2
12.0 mm at L2-L3
15.0 mm at L3-L4
11.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

1. Burst fracture of the L3 vertebral body with retropulsion of a fractured fragment compressing the thecal sac at that level. Fracture of the L3 laminae is also noted.

2. Traumatic rupture of the L2-L3 and L3-L4 intervertebral discs.

3. Altered signal of the L3 vertebral body and upper half of the L4 vertebral body suggests bone bruise.

4. Altered signal in the paravertebral soft tissues bilaterally in the lumbar region may suggest soft tissue injury. Probably minimal epidural and intradural hemorrhage is also noted in the lumbar region.