sb/ke
Date : 00.00.00

Name of the Patient : Abc Xyz. Brlmn / F / 58 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE (left more than right) since 1 month.
H/O fall.

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 slight central wedging of the L2 vertebral body. The L2 vertebral body shows an ill-defined, hypointense signal on the T1 Weighted images which appears hyperintense on the T2 Weighted images. The L2-L3 disc also appears slightly more hyperintense on the T2 Weighted images. Subtle hyperintense signal is seen in the L3 vertebral body.

Left and right far lateral disc protrusion is noted at the L5-S1 level.

A posterior disc bulge is seen at the L4-L5 level with slight right neural foraminal narrowing and minimal indentation on the extraforaminal segment of the right L4 nerve root.

A minimal posterior disc bulge is noted at the L3-L4 level. A small right far lateral disc bulge is seen at the L3-L4 level with indentation upon the extraforaminal portion of the right L3 nerve root.
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The rest of the visualized lumbar vertebral bodies show fatty marrow changes suggesting osteoporosis. Slight anterior wedging of the L1 vertebral body is noted. The remaining lumbar intervertebral discs show loss of water content.

Schmorls nodes are noted in the lumbar region.

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 :

16.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
15.0 mm at L4-L5
15.0 mm at L5-S1.

IMPRESSION :

1. Central wedging of the L2 vertebral body with altered signal most likely represents wedged fracture with bone bruise, in the given clinical setting. Altered signal in the L1-L2 disc may represent discal edema.

2. Bone bruise/edema in the L3 vertebra.

3. Fatty marrow changes in the rest of the visualized lumbar vertebrae may suggest osteoporotic changes.

4. Left and right far lateral disc protrusion at the L5-S1 level.
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5. A posterior disc bulge at the L4-L5 level with slight right neural foraminal narrowing and minimal indentation on the extraforaminal segment of the right L4 nerve root.

6. A posterior and right far lateral disc bulge at the L3-L4 level with indentation upon the extraforaminal portion of the right L3 nerve root.