Date : 00.00.00
Name of the Patient : Abc Xyz Llmn / M / 29 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache (on & off) radiating to BLE since 8 years which has increased since 4-5 months and paresthesias since 4-5 days.
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.
Areas of hypointensity on the T1 Weighted images which turn heterogeneously hyperintense on the T2 Weighted images are seen to involve the L5 vertebral body, transverse processes, pedicles, articular pillars, laminae and spinous process. There appears to be a break of its superior cortical endplate.
There is extension of this pathologic process into the paravertebral soft tissues on the right side over the L4 to S1 vertebral levels. Also seen is extension into the anterior and
right lateral epidural space over the L3 to the S1 vertebral level with encroachement into the L4-L5 neural foramina bilaterally and on the right side at the L5-S1 level. There is resultant indentation of the thecal sac over these levels.
A hypointense focus on the T1 Weighted images is seen in the right iliac bone adjacent to the right sacro-iliac joint.
There appears to be an enlarged interaortico-caval lymphnode at the L3/L3-L4 levels.
- 2 - scan-00009
The L4-L5 intervertebral disc shows loss of water content (?? minimal involvement).
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints and the visualized prevertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1 level and the thecal sac terminates at the S1 level.
The MRI features are suggestive of a pathologic process involving the L5 vertebra with soft tissue extension and a smaller lesion in the right iliac wing as described. The differential diagnosis would include,
1. Infective process like tuberculosis.
2. Neoplasia like a small cell tumor.