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DrThomasMd
DrThomasMd, Board Certified MD
Category: Neurology
Satisfied Customers: 63757
Experience:  Internal medicine doctor, diagnose and treat neurology patients, many years
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I need assistance please MRI SPINE LUMBAR WO CONTRAST -

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I need assistance please
MRI SPINE LUMBAR WO CONTRAST - Details
Narrative
MRI LUMBAR SPINE WITHOUT CONTRAST, 07/24/2015
INDICATION: FALL, DISLOCATION
TECHNIQUE: Multiplanar MRI images of the lumbar spine were obtained without gadolinium contrast.
CONTRAST DOSE: None.
COMPARISON STUDY: No prior MRI for comparison. CT scan of the thoracic and lumbar spine dated 07/27/2014 was reviewed.
FINDINGS:
MRI Lumbar spine:
For the purposes of this dictation, the lowest fully formed lumbar vertebral body is defined as L5. There is partial sacralization at L5-S1.
Mild degenerative disc disease at L4-L5 with mildly decreased T2 bright disc signal. A mild disc bulge at this level mildly indents the thecal sac and abuts the descending left L5 nerve root in the lateral recess. Overall there is mild spinal canal
stenosis at this level which is also contributed to by mild ligamentous hypertrophy and mild bilateral facet arthropathy. An annular fissure is also noted at this level.
The remainder of the intervertebral discs are normal in signal. The vertebral bodies are maintained in height and alignment. The marrow signal is normal. No prevertebral or dorsal paraspinal soft tissue swelling. The anterior and posterior
longitudinal ligaments and ligamentum flavum are normal. No epidural hematoma. The conus medullaris is normal in size and signal and terminates normally at the level of T12-L1.
Impression
IMPRESSION:
No evidence of acute abnormality. Mild degenerative disc disease as described at L4-L5 in the setting of partial sacralization of L5-S1.
HIP MRI
No acute fracture or dislocation of the pelvis and hips is seen. There is mildly increased amount of fluid in both hip joints.
There is desiccation of the L4-L5 intravertebral disc. There is a transitional L5 vertebra with hypertrophy of the L5 transverse processes which articulate with the sacrum. There are some degenerative changes at these articulations with associated mild
bone marrow edema which is more pronounced on the right. This also could be a source of the patient's pain. The bone marrow signal is otherwise unremarkable.
The imaged musculature is grossly unremarkable without evidence of edema or atrophy. There is mild subcutaneous dependent edema in the left sacral region. The imaged tendons about the bilateral hips are grossly unremarkable.
The urinary bladder is moderately distended by urine. The uterus is present and appears unremarkable. No ovarian or pelvic masses are seen.
The vagina is deviated to the right with associated tampon. There is suspected septation within the vagina and suspected thin septation within the uterine cervix without septation within the uterus seen.
The evaluation of the acetabular right labrum is suboptimal on this nonarthrogram study. However, on the sagittal images there is a small high signal intensity cleft projecting over the anterior right acetabular labrum which may represent labral tear.
Submitted: 1 year ago.
Category: Neurology
Expert:  DrThomasMd replied 1 year ago.
There is mild arthritis in the lower spine.
They are worried there is a tear in the socket of the hip.
This needs an MRI with contrast to see if this is the case.
OK, so that is an initial answer….
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