Date : 00.00.00
Name of the Patient : Abc Xyza Glmn / F / 20 yrs.
Referred by : Dr. Abc Xyzosale.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with paresthesias since 6 months.
H/O injury to back 6 months 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.
5 mm thick T1 Weighted and T2 Weighted axial images.
There appears to be sacralization of the L5 vertebra and it is as marked on the film. Please correlate with plain radiographs. There also appears to be a spina bifida of the L5 vertebra.
There are areas of hypointensity on the T1 Weighted images which turn hyperintense on the T2 Weighted images involving the L3 and L4 vertebral bodies and the 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 anterior epidural space with resultant compression of the thecal sac at the L3 and L4 vertebral levels (more so on the left side at the L3 vertebral level). There is encroachment into the L3-L4 neural foramina bilaterally.
- 2 - scan-00000
There is extension into the pre and paravertebral soft tissues with involvement of the psoas muscles at the L3 and L4 levels.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints are unremarkable.
The conus medullaris terminates at the D12 level and the thecal sac terminates at the S1 level.
The cervical and dorsal spines were screened with 4 mm thick T1 Weighted sagittal images and there appears to be enlarged mediastinal lymphnodes.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebra. Please correlate with plain radiographs.
2. A pathologic process involving the L3 and L4 vertebrae and the L3-L4 intervertebral disc with soft tissue extensions as described. This most likely represents an infective lesion like tuberculosis.
The possibility of this being a neoplastic process like a small cell tumor is less likely.