Date : 00.00.00
Name of the Patient : Abc XyzDclmn / M / 31 yrs.
Referred by : Dr. Abc Xyz. Modi.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE since 6-7 days.
H/O fall from a bicycle prior to this.
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.
The sacro-iliac joints were scanned with 4 mm thick T1 Weighted coronal images and 4 mm thick STIR axial images.
OBSERVATION :
There is partial sacralization of the L5 vertebra on the right.
There is loss of water content of the D11-D12, D12-L1, L1-L2 and L4-L5 intervertebral discs.
There is a small, postero-central disc herniation at the L4-L5 level, indenting the dural theca anteriorly.
The D10, D12, L1 and L2 vertebral bodies are slightly wedged, anteriorly and show evidence of fatty marrow changes. Herniation of the corresponding intervertebral discs into the above mentioned vertebral bodies along their superior margin and the L5 vertebra is noted. Type II degenerative change is also noted in the L5 vertebral body.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12-L1 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 :
19.0 mm at L1-L2
18.0 mm at L2-L3
13.0 mm at L3-L4
9.0 mm at L4-L5
10.0 mm at L5-S1.
The images of the sacro-iliac joints reveal an ill-defined, hypointense signal on the T1 Weighted images in the marrow of the sacral and iliac bones adjacent to the right sacro-iliac joint. This lesion appears hyperintense on the STIR images. The cortical margins of the right sacro-iliac joint appear intact. Minimal fluid is noted in the right sacro-iliac joint per se.
The visualized left sacro-iliac joint appears unremarkable.
IMPRESSION :
1. A small, postero-central disc herniation at the L4-L5 level.
2. Slight anterior wedging of the D10, D12, L1 and L2 vertebral bodies with fatty marrow changes may be the sequelae of previous trauma.
3. Altered signal in the sacral and iliac bones adjacent to the right sacro-iliac joint is not specific for a single etiology. These changes may be the sequelae of previous trauma, or may represent sacro-ilitis.
