Date : 00.00.00
Name of the Patient : Abc Xyz Malmn / F / 24 yrs.
Referred by : Dr. Abc Xyzhari.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE.
H/O Tuberculous spine 5 years back. Received AKT.
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.
Areas of hypointensity on the T1 Weighted images which turn heterogeneously hyperintense on the T2 Weighted images are seen to involve the L3, L4, L5 and S1 vertebrae, pedicles of the L4 and L5 vertebrae and the sacral ala of the S1 vertebra. Also seen is involvement of the L4-L5 and L5-S1 intervertebral discs with erosion of the adjacent cortical endplates. There is also lateral subluxation of the L4 over the L5 vertebra.
There is extension of this pathologic process into the anterior epidural space over the L4 to S1 levels and into the pre and paravertebral soft tissues over the L3 to S1-S2 levels. Also seen is encroachment into the L4-L5 and L5-S1 neural foramina bilaterally. There is displacement of the left psoas muscle laterally at the L5 and S1 vertebral levels.
Facetal hypertrophy is seen at the L4-L5 level.
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 S1 level.
The MRI features are suggestive of a pathologic process involving the L3, L4, L5 and S1 vertebrae and the L4-L5 and L5-S1 intervertebral discs as described. This most likely represents an infective process like tuberculosis.
The possibility of this being a neoplastic process is less likely.