ke/bv/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzsalmn / M / 36 yrs.
Referred by : Dr. Abc Xyzchant / Dr. Abc Xyzthwani
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :
C/O backache radiating to the RLE since 3 months.
H/O fall from a height with fracture of the L2 vertebra.

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 partial sacralization of the L5 vertebra on the left side.

There is a fracture of the L2 vertebral body without any signal change.

Small posterior peridiscal osteophytes are noted at the L1-L2 and L2-L3 levels with mild anterior indentation of the thecal sac.

A small posterior disc bulge is seen at the L4-L5 level with ventral indentation upon the thecal sac.

The facet joints at the L3-L4 and L4-L5 levels show hypertrophy.

The lumbar vertebral bodies and the intervertebral discs reveal normal signal intensity. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
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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 :

18.0 mm at L1-L2
17.0 mm at L2-L3
17.0 mm at L3-L4
15.0 mm at L4-L5
13.0 mm at L5-S1.

IMPRESSION :

1. Partial sacralization of the L5 vertebra on the left side.

2. Fracture of the L2 vertebral body without any signal change.

3. Small posterior peridiscal osteophytes at the L1-L2 and the L2-L3 levels.