Date : 00.00.00
Name of the Patient : Abc XyzHarilmn / M / 22 yrs.
Referred by : Dr. Abc Xyzra.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE since July 0000.
For follow up.
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 are hypointense areas on the T1 Weighted images replacing the normal marrow of the L3 vertebral body and pedicles. These areas are seen to turn heterogeneously hyperintense on the T2 Weighted images. There is break in the superior cortical endplate of this vertebra with involvement of the adjoining L2-L3 intervertebral disc. This disc appears reduced in height and shows mild loss of water content. The intranuclear cleft is not well-identified within this disc. There is slight bulging of the vertebra circumferentially.
A small posterior disc bulge is noted at the L4-L5 level.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the 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 :
17.0 mm at L1-L2
15.0 mm at L2-L3
13.0 mm at L3-L4
13.0 mm at L4-L5
12.0 mm at L5-S1.
Screening of the dorsal and cervical spines reveals no feature of note.
The MRI features are suggestive of altered signal of the L3 vertebral body with break in the superior cortical endplate and involvement of the L2-L3 disc is not specific for a single etiology. This most likely is infective in etiology (like tuberculosis).
The possibility of this lesion being neoplastic in origin
seems less likely.
As compared to the previous MRI dated 00.00.00, there is break in the superior cortical endplate with involvement of the L2-L3 intervertebral disc which was not seen on the previous MRI study.