Date : 00.00.00
Name of the Patient : Abc Xyzs Florlmn / M / 33 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
Known C/O Kochs spine at L3-L4 level with excision of discharging sinus and drainage of cold abscess on 00.00.00.
C/O backache since 1 week.
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.
6 mm thick T1 Weighted coronal images.
Areas of hypointensity on the T1 Weighted images which turn hyperintense on the T2 Weighted images are seen to involve the L3 and L4 vertebral bodies. The L3-L4 intervertebral disc is also involved with erosion of the adjacent cortical end-plates.
There is mild extension into the left paravertebral soft tissues over the L3-L4 to the L5-S1 levels and into the right paravertebral soft tissues at the L3-L4 and L4 levels. Mild extension into the prevertebral soft tissues is seen over the L3-L4 to the L4-L5 levels. Slight encroachment of this pathologic process is seen into the left L3-L4 neural foramen.
Posterior peridiscal osteophytes are noted at the L3-L4 level.
Posterior disc bulges are seen at the L4-L5 and L5-S1 levels. Facetal hypertrophy is noted at these levels.
The L4-L5 intervertebral disc shows loss of water content.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints are unremarkable.
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 :
16.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
15.0 mm at L4-L5
14.0 mm at L5-S1.
In a known C/O tuberculosis of the spine, the MRI features are suggestive of involvement of the L3 and L4 vertebrae and L3-L4 intervertebral disc with soft tissue extensions as described.
As compared to the previous MRI (only T2 Weighted axial images were available) dated 00.00.00, there is a decrease in the size of the soft tissue component.