Date : 00.00.00
Name of the Patient : Abc Xyz Llmn / M / 29 yrs.
Referred by : Dr. Abc Xyzabhar / Dr. Abc Xyzkumar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE.
Has received 18 cycles of Radiotherapy for Non-Hodgkins lymphoma.
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 appears to be hemi-laminectomy of the L5 and S1 vertebrae on the right side.
Areas of hypointensity on the T1 Weighted images which turn heterogeneously hyperintense on the T2 Weighted images are seen to involve the L5 vertebral body, the transverse processes, pedicles and articular pillars. There appears to be a suspicious break of its superior cortical endplate.
There is extension of this pathologic process into the paravertebral soft tissues on the right side over the L4 to S1 vertebral levels. Also seen is extension into the anterior and
right lateral epidural space over the L3 to the S1 vertebral level with encroachment into the L4-L5 neural foramina bilaterally and on the right side at the L5-S1 level. In some parts, the soft tissue is seen to encircle the thecal sac. There is resultant indentation of the thecal sac over these levels.
A hypointense focus on the T1 Weighted images is seen in the right iliac bone adjacent to the right sacro-iliac joint.
- 2 - scan-00007
The L4-L5 intervertebral disc shows loss of water content. The L3-L4 intervertebral disc shows mild loss of water content.
The rest of the lumbar vertebral bodies reveal areas of fatty replacement of normal marrow. Fatty changes are also visualized in the L5 vertebral body on the left side. This may suggest healing of the disease process.
The conus medullaris terminates at the L1 level and the thecal sac terminates at the S1 level.
In a known C/O Non-Hodgkins lymphoma, the MRI features are suggestive of the pathologic process involving the L5 vertebra with soft tissue and epidural extension and a smaller lesion in the right iliac wing as described.
As compared to the previous MRI dated 00.00.00 (Study No.00002),
there is no significant change.