Date : 00.00.00
Name of the Patient : Abc Xyzkh Dlmn / M / 47 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with numbness since 1 year which has increased since 4 months.
H/O fall 1 year back.
M.R.I of the lumbo-sacral spine was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted sagittal images.
6 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 L3 and L4 vertebral bodies and pedicles. Also seen is involvement of the L3-L4 intervertebral disc with erosion of the adjacent cortical endplates.
There is extension of this pathologic process into the paravertebral soft tissues and psoas muscles bilaterally at the L3 and L4 vertebral levels.
A small posterior disc herniation with small peridiscal osteophyte is seen to indent the thecal sac at the L2-L3 level. A right far lateral (extraforaminal) disc herniation is also seen at this level. Mild bilateral foraminal narrowing is also seen at this level.
Bilateral small postero-lateral (foraminal) disc herniations are seen at the L4-L5 level with resultant mild neural foraminal narrowing bilaterally.
There is a posterior disc bulge at the L5-S1 level. Also seen is a left far lateral (extraforaminal) disc bulge at the L2-L3 level.
There is an anterior disc herniation with peridiscal osteophytes at the L2-L3 level. Type II degenerative changes are noted in the L2 vertebral body.
The rest of the lumbar intervertebral discs show loss of water content.
The conus medullaris terminates at the L1 level and the thecal sac terminates at the S2 level.
The MRI features are suggestive of osteitis and discitis of the L3 and L4 vertebrae and L3-L4 intervertebral disc, respectively with soft tissue extensions as described. This most likely represents an infective process like tuberculosis.
The possibility of this being a neoplastic process is less likely.