X-Ray Report

Name:                Withheld                    DOB:                   25/06/80

Date of Study:    20/01/07                  Date of Report:     18/11/07

Cervical Spine 
AP, APOM and neutral lateral cervical spine films are provided. Slightly reduced cervical lordosis. The right angle of mandible projects inferior to the left, with corresponding mild levo-convex scoliosis, apex at C5. Normal bone density. There is a very minor retrolisthesis of C3. The intervertebral disc spaces, facet and unco-vertebral joints are normal. The ADI measures 2mm. All pre-vertebral soft tissues spaces are within normal limits. The visualised apical lung fields are normal. No other abnormality detected.

Clinical Impression:

1.Postural changes are described.

2.Very mild retrolisthesis of C3

Thoracic Spine

AP and lateral thoracic spine projections provided. All osseous alignment and bone density is normal. Normal joint appearance. No abnormality is detected within the visualised lung fields. No other abnormality detected.

Clinical Impression:

1. Normal study

Lumbar Spine and Pelvis
Frontal lumbo-pelvic and lateral lumbar spine radiographs supplied. Very mild right lateral list originating at the lumbo-sacral segment. However this is accentuated by a slight right posterior rotation of the patient due to positioning error. The lumbar gravity line falls 11mm anterior to the sacral promontory. Normal bone density.

All intervertebral disc spaces are normal as are all visualised facet joints. Of incidental note, a spina-bifida occulta of S1 is observed. The sacro-iliac joints and pubic symphysis are normal, as are the coxo-femoral joints. A left pubic ear is noted projecting into the corresponding obturator foramen, (developmental variant of no clinical significance). Normal renal outlines. No other abnormality detected.

Clinical Impression:
1. Normal study                                                                                  

X-Ray Report

Name:            Withheld
DOB:              9^th July, 1943
Date of Study:1^st October, 2005
2^nd November, 2005

Lumbar Spine and Pelvis

Radiologic Findings:

Frontal and lateral lumbar spine, frontal pelvis and left sacro-iliac views are submitted.

There is moderate generalised osteopaenia. The left superior pubic ramus demonstrates a focal lytic, destructive process of bone with an ill-defined inferior cortex in this region. The superior cortex is mildly expanded, though this may be due to superimposition of the ischial spine The lesion demonstrates a wide zone of transition. Kohler’s teardrop is obliterated. The optical density of the surrounding soft tissues indicate probable soft tissue infiltration.

The iliofemoral joints bilaterally demonstrate only mild loss of superior joint space and acetabular sub-chondral sclerosis consistent with a patient of this age. The gluteal and external rotator fat planes are normal. A degenerative enthesiophyte is observed at the gluteus medius insertion on the left greater trochanter.

The superior aspect of the ilium at the left sacro-iliac joint demonstrates an area of local osteopaenia. This ill-defined area may represent further permeative pattern of bone destruction, although it is not well visualised due to superimposition of intestinal gas. The sacro-iliac joints are well maintained bilaterally.

The lumbar spine identifies only mild degenerative changes with mild loss of posterior intervertebral disc height throughout, though most evident at T11/12. L5 demonstrates a grade 1 degenerative spondylolisthesis, lumbo-sacral facet arthrosis and mildly hyperplastic transverse processes. A mild left lateral list extending from L2 is noted.

Surgical staples are observed in the soft tissues of the right flank consistent with a history of renal resection. The liver is visualised and ptotic. 

All other soft tissues and joint spaces are normal. No other abnormality is detected.

Clinical Impression:

1. Probable lytic metastatic disease involving the left superior pubic ramus and possibly involving the sub-chrondral region of the left ilium at the sacro-iliac joint. However, an aggressive infectious process or primary sarcomatous lesion cannot be ruled out on these images.
2. Moderate generalised osteoporosis.
3. Mild degenerative disc disease and lumbo-sacral facet arthrosis.
4. L5 grade 1 degenerative spondylolisthesis.

Recommendations:

Immediate referral for further evaluation of the destructive osseous lesions. I recommend scintigraphic evaluation, MRI and histological analysis.

MRI Report

Name: Withheld                      Date of Birth: 21/06/30

Date of Study:25/10/07         Date of Report: 17/11/07

Lumbar spine

Clinical history: 

Left leg pain. Likely L4/5 disc lesion

Interpretation:

Sagittal T1 and T2 weighted and Axial T2 weighted sequences of the lumbar spine are provided for interpretation.

There is increased T1 and T2 weighted signal intensity within the vertebral body bone marrow adjacent to the endplates throughout all lumbar segments, most notably L2/3/4, consistent with Type 2 Modic change. This corresponds with reduced disc height and loss of signal intensity most severe at L2/3 and L3/4 with associated endplate irregularity, and anterior and posterior osteophytic proliferation. L2 demonstrates a 6mm retrolisthesis on L3. Schmorls nodes are evident in the superior endplate of L2 and the inferior endplate of T12. A 10mm ovoid area of increased T1 and T2 signal intensity is observed within the vertebral body of T12 representing a benign hemangioma of no clinical significance. A moderate dextro-convex scoliosis is observed, apex at L3.

Viewed axially:

Clinical Impression:

1. Dextro-convex scoliosis causing some mid-lumbar left foraminal narrowing.
2. Moderate-severe lumbar degenerative disc disease, predominantly L2/3/4.
3. T12 hemangioma
4. Left L4 nerve root impingement.
5. Right L5 and S1 nerve root impingement due to probable synovial cyst.

Clinical note to the Physician:

The symptoms described are probably due to the IVF stenosis caused by chronic facet hypertrophy and a left osteophytic bar. Both are osseous abnormalities with surrounding soft tissue changes. Your report of an improvement in the left patella reflex with treatment suggests that there may be some transient compression coupled with local inflammatory mediators. Improvement of segmental motion may alter local transient nerve compression, however amelioration in symptoms is likely to be short-lived and long term relief would likely only be maintained with on-going care or surgery.

The right-sided synovial cyst is a benign lesion which can be asymptomatic, however complications can arise such as haemorrhage which can result in medical urgency. Chiropractic treatment has been shown to improve pain scores, though not affect the lesion itself. Surgical resection or aspiration has been shown to be effective, though not required unless symptomatic.

Thankyou for your referral for chiropractic interpretation of this patient.

X-Ray Report

Name:                          Withheld                       Patient Number:          Withheld

Date of Report:           1^st February 2007          Date of Study: 20^th January 2007

Cervical Spine:

AP, Lateral and APOM projections are provided.

There is a permeative pattern of bone destruction predominating in the C3 spinous process and extending into the lamina. Further small lytic areas are seen in the posterior-superior corner of the C3 vertebral body. A loss of cortical distinction is observed at the margins of the spinous process and spino-laminar junction, coupled with a local reduction of bone density. No soft tissue changes are seen in this region. 

X-Ray Report

Name:             Withheld                    Date of Study:        22^nd October 2005

DOB: 24^th October, 1918                  Date of Report:      23^th October, 2005

Lumbar Spine

Radiologic Findings:

Multiple frontal lumbar, pelvis and lateral lumbar spine views are submitted.

There is marked generalised osteoporosis. T12 demonstrates a 50% loss of vertebral body height affecting the anterior and middle columns, with L1 and L2 also demonstrating endplate collapse but maintaining 70% and 85% of their heights respectively.

Moderate anterior vertebral body osteophytosis and lateral claw osteophytes are observed throughout the lumbar spine with advanced intervertebral disc space narrowing at L4/5 and L5/S1. There are less marked degenerative changes in the superior lumbar segments. The lower lumbar facet joints further demonstrate sclerosis and hypertrophy, consistent with widespread degeneration.

A mild thoracolumbar dextroscoliosis is noted arising from L4 and terminating at T10, with apex at L1.

The sacroiliac joints are well visualised and preserved. The right iliofemoral joint identifies complete loss of the axial joint space, marked subchondral sclerosis, geodes, osteophytes and protrusion acetabulae. The left joint also demonstrates marked degenerative change, although less severe.

Linear calcific concretions are observed in the abdominal aorta, bilateral common iliac and femoral arteries. There is no evidence of pathologic dilatation.

Of incidental note, an irregular opacity is observed in the medullary region of the right femoral neck, demonstrating a brush border. This lesion represents a benign enostoma.

No other abnormality is detected.

Clinical Impression:

1. Multiple osteoporotic insufficiency fractures involving T12, L1 and L2.
2. Marked spondylosis and degenerative disc disease.
3. Advanced osteoarthritis of the iliofemoral joints, with severe involvement on the right.
4. Atherosclerosis. The involvement of the femoral arteries bilaterally indicate a strong correlation with diabetes.

Recommendations:

Clinical monitoring of osteoporosis is essential with review of medication. If previously undiagnosed referral for bone mineral density evaluation is indicated due to the presence of multiple lumbar insufficiency fractures.

The presence of monkeberg’s arteriosclerosis within the femoral arteries is associated with diabetes and clinical correlation is recommended.

X-Ray Report

Name:             Withheld                    Date of Study:        28^th June, 2006

DOB: 28^th November, 1938              Date of Report:      31^st July, 2006

Cervical Spine

Radiologic Findings:

AP, APOM and lateral cervical spine projections are supplied.

Generalised moderate osteopaenia is observed with the body of C2 appearing slightly more osteopaenic than adjacent segments, in all three views. There is no evidence of insufficiency fracture, altered cortices or abnormal intervertebral disc space. The retropharyngeal interspace is normal. These appearance are in keeping with a haemangioma.

There is significant loss of the cervical lordosis with a mild acute kyphosis at C5/6. A mild loss of intervertebral disc height is observed at this level and the level below. Also demonstrated here are small anterior and posterior osteophytes.

The facet joints are moderately degenerated bilaterally, especially in the mid to lower cervical spine. The uncinate processes are hyperplastic and sclerotic at C4 – C6 bilaterally.

The lateral view demonstrates all segments to T2 which may be associated with tension on the brachial plexus – ‘long neck syndrome’  Ossification of the posterior atlanto-occipital membrane is observed bilaterally coupled with failure of ossification of the posterior tubercle of atlas. The anterior tubercle appears somewhat ‘hazy’ and possibly hypertrophic on the lateral view and is not visualised on the APOM projection due to hyperextension of the occiput. This view does however demonstrate a 3mm overhanging margin of C1 lateral mass on the left. This appearance of the anterior tubercle coupled with the posterior spondyloschisis and unilateral overhanging margin suggests a possibility of anterior rachischisis or ‘split atlas’.

The left C7 transverse process is mildly hyperplastic.

No abnormality is detected within the soft tissues and the lung fields are clear as visualised. 

No other abnormality is detected. 

Clinical Impression

1. Postural changes as described above
2. Mild degenerative disc disease of C5/6, C6/7.
3. Moderate facet and uncovertebral joint arthrosis mid-lower cervical spine.
4. Moderate osteoporosis
5. C3 vertebral body haemangioma of no clinical significance.
6. Hyperplastic C7 transverse process
7. Bilateral posterior ponticles
8. Posterior spondyloschisis with possible anterior rachischisis.

Recommendations:

1. The posterior spondyloschisis is a normal variant of no clinical significance, however coupled with the appearance of the anterior tubercle on the lateral view and the unilateral overhanging margin of the lateral mass suggests a strong possibility of anterior rachischisis and should be followed up with axial CT imaging of the atlas.