PROVISONAL REPORT

Date : 01.0000

Name of the Patient : Abc Xyzar Slmn / M / 25 yrs.
Referred by : Dr. Abc Xyzngaonkar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

H/O fall from a height on 00.00.00.
C/O paraplegia with bladder involvement since then.

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 a decrease in the height of the L2 vertebral body with anterior wedging. A fracture line is seen to course through the posterior aspect of this vertebral body. Also seen is a break of the superior cortical endplate (probably of the inferior cortical endplate too). The L2 vertebral body and pedicles show hypointense signal on the T1 Weighted imags which turns hyperintense on the T2 Weighted images and which would represent bone edema. Also seen is a fracture of both laminae. There is rupture of the supraspinous and interspinous ligaments at this level.

The L2 vertebral body is seen to bulge posteriorly with resultant indentation upon the conus medullaris. The lower cord and conus medullaris over the D12 to L2 levels shows a hyperintense signal on the T2 Weighted images and which would represent cord edema/contusion. The cord and conus medullaris over these levels are seen to be swollen.
An intermediate signal intensity lesion in the anterior epidural space at the L2 vertebral level may represent slight epidural haemorrhage. A left paracentral disc protrusion is noted at the L2-L3 level.

Hyperintense signal on the T2 Weighted images is noted within the paraspinal soft tissues over the L1 to L3 vertebral levels and which would represent soft tissue edema.
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A postero-central disc protrusion is seen to indent the thecal sac at the L5-S1 level. A posterior disc bulge is noted at the L4-L5 level. The facet joints at these levels show degenerative changes.

The visualized urinary bladder is marked distended.

The D12-L1 intervertebral disc shows loss of water content.

The conus medullaris terminates at the L2 level and the thecal sac terminates at the S2 level.

IMPRESSION :

In a known C/O trauma, the MRI features are suggestive of :

1. Fracture of the L2 vertebra.

2. Cord compression with cord edema/contusion over the D12 to L2 vertebral
levels.