Date : 00.00.00
Name of the Patient : Abc Xyzi Glmn / F / 45 yrs.
Referred by : Dr. Abc Xyzidhungat.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
Past H/O cholecystitis and psoas abscess (Pott's disease). On AKT since 8 months.
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 is partial collapse of the L5 and S1 vertebral bodies.
There are still seen areas of hypointensity on the T1 Weighted images which turn predominantly hyperintense on the T2 Weighted images involving the L4, L5, S1 and S2 vertebral bodies, the sacral ala of the S1 vertebra, the pedicles of the L5 vertebra and the L5-S1 intervertebral disc. Also seen is slight hyperintense signal on the T2 Weighted images in the antero-inferior portion of the L3 vertebral body.
There is extension of this pathologic process into the spinal canal with resultant compression upon the thecal sac at the L5 and S1 vertebral levels. Also seen is extension into the pre and paravertebral soft tissues over the L3 to S2 vertebral levels and into the paraspinal soft tissue at the L5 and S1 vertebral levels. Also seen is encroachment into the neural foramina at the L5-S1 level bilaterally.
The left iliac bone is also involved by the pathology (se/im 105/6, 104/5).
The rest of the lumbar intervertebral discs show loss of water content.The remaining lumbar vertebral bodies reveal normal signal intensity. The conus medullaris terminates at the L2 level.IMPRESSION :The MRI features are suggestive of partial collapse of the L5 and S1 vertebral bodies with altered signal in the L3, L4, L5, S1 and S2 vertebrae with extensions as described. This is most probably due an infective process like tuberculosis.A neoplastic process like a small cell tumor is less likely.
As compared to the previous MRI dated 00.00.00 (Study No.00004) there is :
a. Reduction in the size of the prevertebral soft tissue lesion.
b. Healing of the L3 vertebral body lesion.
c. Lesion in the left iliac bone is unchanged.
d. Partial collapse of the L5 and S1 vertebral bodies.