Date : 00.00.00
Name of the Patient : Abc Xyz Salmn / M / 45 yrs.
Referred by : Dr. Abc Xyzbar.
Examination : M.R.I. of the Dorso-lumbar Spine.
CLINICAL PROFILE :
C/O backpain radiating to BLE with fever since 2 months.
H/O fall prior to this.
M.R.I of the dorso-lumbar 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 partial sacralization of the L5 vertebral body on the left side which is as marked on the film. Spina bifida is also noted at this level.
There is replacement of the normal marrow of the D12, L1, L2, L3 and L4 vertebral bodies by hypointense areas on the T1 Weighted images. These are seen to turn heterogeneously hyperintense on the T2 Weighted images. The cortical endplates adjacent to the D12-L1, L1-L2, L2-L3 and L3-L4 intervertebral discs are breached with involvement of the respective discs. There is anterior epidural extension to the right of the midline over the L1 to the L3 levels with mild encroachment into L2-L3 neural foramina on the right side and encasement of the right L2 nerve root.
Small posterior disc bulges are seen at the L3-L4 and L4-L5 levels.
The rest of the visualized dorso-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 visualized dorso-lumbar spinal cord reveals normal signal intensity.
The conus medullaris terminates at the D12 level.
The cervico-dorsal spine was screened with 4 mm thick T1 Weighted sagittal images, which reveals altered signal of C5 and C6 vertebrae. There is no significant cord compression.
The MRI features are suggestive of altered signal of the D12, L1, L2, L3 and L4 vertebral bodies and the intervening intervertebral
discs with epidural extensions as described. This most probably represents a infective process like tuberculosis.
The possibility of this being a round cell tumor is less likely.
The C5 and C6 vertebral bodies also show altered signal.