Date : 00.00.00
Name of the Patient : Abc Xyz Ralmn / F / 20 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache and neckpain with occasional fever since 1 year.
Detected to have Potts spine with psoas abscess at the L2-L3 level on 00.00.00. Received AKT for 6 months.
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.
There is an ill-defined, hypointense signal on the T1 Weighted images involving the marrow of the L2, L3 and L4 vertebral bodies. These vertebrae show a subtle, hyperintense signal on the T2 Weighted images. The L3-L4 intervertebral disc is reduced in height and shows a hyperintense signal on the T2 Weighted images. The intranuclear cleft is not well-identified at this level. Irregularity of the cortical endplates adjacent to the L3-L4 disc is noted.
There is seen a fairly large intermediate signal intensity mass lesion on the T1 Weighted images along the left psoas muscle extending over about L2 vertebral level upto the left lateral pelvic wall. This lesion appears hyperintense on the T2 Weighted images and represents a psoas abscess. The left psoas muscle is not well-identified separately from the lesion. Similar signal intensity lesion is also noted in the left neural foramen at the L2-L3 and L3-L4 levels and in the anterior epidural space at the L2 and L3 vertebral levels. Minimal indentation on the exiting left L2 and L3 nerve roots is noted.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and right 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 :
17.0 mm at L1-L2
13.0 mm at L2-L3
13.0 mm at L3-L4
11.0 mm at L4-L5
10.0 mm at L5-S1.
Screening of the dorsal and cervical spines reveals no feature of note.
1. Altered signal of L2, L3 and L4 vertebral bodies with involvement of the L3-L4 intervertebral disc suggest osteitis with discitis, most likely tuberculous in etiology.
2. Soft tissue lesion in the left paravertebral region extending from the L2 vertebral level into the pelvis as described represents a psoas abscess.