Date : 00.00.00
Name of the Patient : Abc Xyzngh lmn / M / 29 yrs.
Referred by : Dr. Abc Xyzonawalla.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE since 1 month.
Alleged H/O lifting heavy weights.
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.
The sacro-iliac joints were screened with 4 mm thick STIR coronal images and 5 mm thick T1 Weighted axial images.
Areas of hypointensity on the T1 Weighted images which turn hyperintense on the STIR images are seen to involve the iliac wing and sacral ala on the left side with involvement of the adjacent left sacro-iliac joint. There is probable extension into the soft tissues anteriorly.
There is a postero-central disc protrusion at the L5-S1 level. This disc shows loss of water content and appears reduced in height.
A posterior disc bulge is noted at the L4-L5 level.
Mild facetal hypertrophy is seen at the L4-L5 and L5-S1 levels.
A small area of hypointensity on the T1 Weighted images which turns hyperintense on the T2 Weighted images is seen within the antero-superior aspect of the L5 vertebral body (se/im 102/2 & 103/2 - ? Type II degeneration ? osteitis).
- 2 - Scan-00007
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12-L1 level and the thecal sac terminates at the S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
17.0 mm at L1-L2
15.0 mm at L2-L3
15.0 mm at L3-L4
14.0 mm at L4-L5
10.0 mm at L5-S1.
The MRI features are suggestive of a pathologic process involving the left sacro-iliac joint and which most likely represents sacro-ilitis (? infective).
This is less likely to be a neoplastic process.