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ke/sb/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz M. Shillmn / M / 40 yrs.
Referred by : Dr. Abc Xyzrankar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

H/O tuberculous spine for which patient was operated in August 0000 (no details available). Patient on AKT since then.
Mild weakness of BLE still persists with mild backache and involuntary jerks in BLE.

EXAMINATION :

M.R.I of the lumbo-sacral spine was performed using the following parameters :

5 mm thick T1 Weighted and T2 Weighted sagittal images.

6 mm thick T1 Weighted and T2 Weighted axial images.

OBSERVATION :

There is evidence of operative intervention in the left paraspinal region with susceptibility artifacts at the D11 and D12 levels.

There is replacement of the normal marrow of the D12 and L1 vertebral bodies by hypointense areas on the T1 Weighted images. This is seen to turn heterogeneously hyperintense on the T2 Weighted images. The superior and inferior cortical endplate of the D12 and L1 vertebral bodies is breached with involvement of the D12-L1 disc. The left pedicle of the D12 and L1 vertebral body and the left transverse process of the D12 vertebra is involved by the pathology. There is a soft tissue lesion in the left paraspinal region at the D12 level which is of intermediate signal on the T1 Weighted images and turns hyperintense on the T2 Weighted images. Anterior epidural extension is noted over the D12 and L1 levels.
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Small postero-central disc herniations are seen at the L4-L5 and L5-S1 levels with anterior indentation of the thecal sac. These discs show loss of water content.

The cerivco-dorsal spine was screened with 4 mm thick T1 Weighted sagittal images and does not reveal any diagnostic feature of note.

The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints 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 :

19.0 mm at L1-L2
19.0 mm at L2-L3
18.0 mm at L3-L4
12.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

Altered signal in the D12 and L1 vertebral bodies and the D12-L1 intervertebral disc with extensions as described may be due to granulomatous infective process like tuberculosis. Minimal anterior epidural and left paravertebral soft tissue lesion is noted.

As compared to the previous MRI dated 00.00.00, the soft tissue lesion at the D12 level on the left is a new feature.

The patient is status post-operative.
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