ke/bv/rg.

Name of the Patient : Abc Xyza lmn / M / 45 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE since 4-5 years.
H/O fall from a height with a subsequent spinal surgery 26 years ago.

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 :

The lumbar intervertebral discs show loss of water content.

There is laminectomy at the L1 vertebral level with post-operative changes in the soft tissues of the back.

There is anterior wedging of the D12 vertebral body with slight wedging of the D11 vertebra and the mild angular kyphus at that level. An osteophyte at the postero-superior portion of the D12 vertebral body is seen to indent the anterior aspect of the cord. There is no change in signal intensity of the vertebral bodies.

The spinal cord at the D10, D11 and D12 vertebral levels shows a hypointense signal on the T1 Weighted images and turns hyperintense on the T2 Weighted images and would represent myelomalacia.

There is slight retroplacement of the L3 over the L4 vertebral body with a pseudoposterior disc herniation at the L3-L4 level, anterior indentation of the thecal sac and bilateral neural foraminal narrowing.
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A diffuse posterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L4-L5 facet joints show hypertrophic degenerative changes with resultant lateral canal stenosis.

A posterior and left postero-lateral disc herniation is noted at the L2-L3 level.

Small posterior disc bulges are seen at the L1-L2 and L5-S1 levels.

Schmorl s nodes are seen in the lumbar region.

The rest of the lumbar vertebral bodies reveal normal signal intensity. The rest of 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 S2 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

15.0 mm at L1-L2
15.0 mm at L2-L3
12.0 mm at L3-L4
10.0 mm at L4-L5
9.0 mm at L5-S1.

Screening of the dorsal spine reveals no feature of note.

IMPRESSION :

1. Post-operative status.

2. A diffuse posterior disc herniation with hypertrophic facetal arthropathy and resultant lateral canal stenosis at the L4-L5 level.
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3. A posterior and left postero-lateral disc herniation at the L2-L3 level.

4. Anterior wedging of the D12 vertebral body with slight wedging of the D11 vertebra may be the result of previous trauma.

5. Altered signal of the spinal cord over the D10 to the D12 vertebral levels would represent myelomalacia.