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sb/hs/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz Plmn / M / 29 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE with paresthesias since 1 month.

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 L5 vertebral body appears hypointense on the T1 Weighted images and heterogeneously hyperintense on the T2 Weighted images. Erosion of the right lateral margin of the L5 vertebral body is noted. There is also erosion of the inferior cortical endplate of the L5 vertebral body with involvement of the L5-S1 intervertebral disc.

There is seen an intermediate signal intensity soft tissue lesion on the T1 Weighted images in the right paravertebral and anterior epidural space at the L5 and S1 vertebral levels. This lesion appears hyperintense on the T2 Weighted images. Extension of the soft tissue lesion into the right neural foramen at the L5-S1 level is noted with probable extension of the soft tissue lesion along the left L5 nerve root in the left neural foramen at the L5-S1 level. Subtle hypointense signal on the T1 Weighted images is also noted in the S1 vertebral body adjacent to the L5-S1 disc.


A minimal posterior disc bulge is noted at the L4-L5 level.

The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints are unremarkable.

A lesion is seen to arise from the lateral aspect of the right kidney. This may require further evaluation (eg.Sonography).

The conus medullaris terminates at the 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
16.0 mm at L2-L3
15.0 mm at L3-L4
13.0 mm at L4-L5
6.0 mm at L5-S1.

IMPRESSION :

Altered signal of the L5 and S1 vertebral bodies and the L5-S1 disc most likely represents osteitis with discitis, probably tuberculous in etiology. Right paravertebral and anterior epidural soft tissue lesion may represent granulation tissue/abscess.

The possibility of this lesion representing a neoplasm seems less likely.






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