Date : 00.00.00
Name of the Patient : Abc Xyz Jalmn / M / 63 yrs.
Referred by : Dr. Abc Xyzchale.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE since 00.00.00.
H/O fever since 1 month.
H/O fall in November 0000.
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 replacement of the normal marrow of the L2, L3, L4 and L5 vertebral bodies by hypointense areas on the T1 Weighted images. These are seen to turn heterogeneously hyperintense on the T2 Weighted images. The pedicles of the L4 and L5 vertebrae are involved by the pathology. The L4-L5 intervertebral disc appears hyperintense suggestive of its involvement. There is slight pre and paravertebral soft tissue extension over the L4 to the L5 levels. The psoas muscles bilaterally show multiple hypointense areas on the T1 Weighted images which are seen to turn heterogeneously hyperintense on the T2 Weighted images. Anterior epidural extension is also noted extending over the D12 to the L2 levels. There is also encroachment into the neural foramen on the left side at the L4 level with encasement of the foraminal L4 nerve roots.
The CSF in the lumbar canal appears slightly hyperintense to normal on the T1 Weighted images.
Small posterior disc herniations are noted at the L2-L3, L4-L5 and L5-S1 levels.
The rest of the lower dorsal and lumbar intervertebral discs show loss of water content.
The rest of the lumbar vertebral bodies reveal normal signal intensity. The facet joints are unremarkable.
The conus medullaris terminates at the L1 level and the thecal sac terminates at the S1 level.
Note is made of a renal cyst in the left kidney.
The cervico-dorsal spine was screened with 4 mm thick T1 Weighted sagittal images and which shows degenerative changes more marked at the C5-C6 and C6-C7 levels with a tight canal at the C5-C6 level.
The MRI features are suggestive of altered signal in the L2, L3, L4 and L5 vertebrae and the L4-L5 disc with extensions as described. This most probably is infective in etiology (like tuberculosis).
The possibility of a neoplastic process like a small cell tumor is less likely.