s Date : 00.00.00
Name of the Patient : Abc Xyzandlmn / M / 71 yrs.
Referred by : Dr. Abc Xyznshah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE since 3 months.
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.
The hip joints and sacro-iliac joints were screened with 6 mm thick T1 Weighted coronal and axial images.
SOME IMAGES SHOW PATIENT MOTION.
There is loss of water content of all the lumbar intervertebral discs except the L2-L3 disc.
There is an ill-defined, hypointense signal on the T1 Weighted images in the L2 and L3 vertebral bodies, which appears heterogeneously hyperintense on the T2 Weighted images. There is erosion of the cortical endplates adjacent to the L2-L3 disc with involvement of the L2-L3 disc. There is right paravertebral and anterior epidural soft tissue lesion at the L2 and L3 vertebral levels which are of intermediate signal on the T1 Weighted images and hyperintense on the T2 Weighted images. Encasement of the L2 nerve roots in the neural foramina at the L2-L3 level is noted bilaterally. There is resultant thecal sac compression by the anterior epidural soft tissue lesion.
There is minimal forward translation of the L4 over the L5 vertebra without obvious lysis. A pseudoposterior and left postero-lateral disc herniation is noted at the L4-L5 level. There is also facetal hypertrophy and canal stenosis at that level.
A small posterior disc bulge is noted at the L3-L4 level.
A small left postero-lateral disc bulge is noted at the L1-L2 level.
The facet joints at the L2-L3 level also appear slightly hypertrophied.
The rest of the lumbar vertebral bodies reveal spotty fatty changes suggesting osteoporosis. The visualized prevertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12-L1 level and the thecal sac terminates at the S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
14.0 mm at L1-L2
6.0 mm at L2-L3
12.0 mm at L3-L4
9.0 mm at L4-L5
12.0 mm at L5-S1.
Screening images of the S. I. joints and hip joints do not reveal any significant feature of note.
- 3 - Scan-00002
1. Altered signal of the L2 and L3 vertebral bodies and the L2-L3 disc as described, most likely represents osteitis with discitis, probably tuberculous in etiology. Right paravertebral and anterior epidural soft tissue lesion may represent granulation tissue/abscess.
The possibility of a neoplasm cannot be entirely excluded, though less likely.
2. Minimal forward translation of the L4 over the L5 vertebra without obvious lysis.
3. A pseudoposterior and left postero-lateral disc herniation at the L4-L5 level with facetal hypertrophy and canal stenosis at that level.