ke/bv
Date : 00.00.00

Name of the Patient : Abc Xyz. lmn / M / 30 yrs.
Referred by : Dr. Abc Xyzpe.
Examination : M.R.I. of the Dorso-lumbar Spine.

CLINICAL PROFILE :

Alleged H/O trauma (fall of heavy weight) on 00.00.00.
C/O progressive weakness of BLE (L>R) since then.

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 anterior wedging of the D12 vertebral body and is retroplaced as compared to the L1 vertebra. There is suggestion of a fracture of the lamina and the spinous process of the D12 vertebral body. There is disruption of the D11-D12 facets.

There are hypointense areas in the superior portion of the D12 vertebral body which are seen to turn heterogeneously hyperintense on the T2 Weighted images and would represent bone edema/contusion in the given clinical setting. The superior cortical endplate of the D12 vertebra appears broken (fractured). The postero-superior portion of the D12 vertebral body is seen to compress upon spinal cord. The spinal cord at the D11 and D12 levels shows a hyperintense signal on the T2 Weighted images and is isointense to the cord on the T1 Weighted images
suggestive of cord edema/contusion.

There is an intermediate signal intensity lesion in the anterior epidural region at the D11 level on the T1 Weighted images which is seen to turn hyperintense on the T2 Weighted images and may represent haemorrhage (scans 106.7, 106.8, 107.7, 107.8, 104.3, 104.4, 105.3, 105.4).

The anterior longitudinal ligament appears stripped away from the D12 vertebra.

The paraspinal soft tissues at the D12 level shows altered signal intensity suggestive of edema/contusion. The paraspinous soft tissues at this level also shows altered signal intensity suggestive of edema/contusion.
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A small pseudo-posterior disc bulge is noted at the D12-L1 level.

The rest of the visualized dorso-lumbar vertebral bodies and intervertebral discs reveal normal signal intensity.

The conus medullaris terminates at the L1-L2 level.

The lumbar spine was screened with 5 mm thick T1 Weighted sagittal images which shows a small posterior disc herniation at the L5-S1 level.

IMPRESSION :

In a known C/O trauma the MRI features are suggestive of anterior wedging of the D12 vertebra with fracture of the lamina and spinous process with bone edema/contusion at this level as described. Altered signal of the cord at the D11 and D12 levels suggests cord edema/contusion with probable haemorrhage in the anterior epidural region at the D11 level.