Date : 00.00.00
Name of the Patient : Abc Xyzvati C. lmn / F / 60 yrs.
Referred by : Dr. Abc Xyzchale.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 2-3 months.
C/O retention of urine and loose motions since 00.00.00.
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 slight wedging of the L2 vertebral body. The L1, L2 and upper half of the L3 vertebral body and the L4 vertebral body appear hypointense on the T1 Weighted images and heterogeneously hyperintense on the T2 Weighted images. The L1-L2 and L2-L3 intervertebral discs show normal height and signal intensity. Probable erosion of the superior cortical endplate of the L2 vertebral body is noted. There is seen an intermediate signal intensity soft tissue lesion on the T1 Weighted images in the prevertebral, left paravertebral and anterior epidural region extending over the L1 and L2 vertebral levels. This lesion appears heterogeneously hyperintense on the T2 Weighted images. There is resultant thecal sac compression at these levels. Extension of this soft tissue lesion into the neural foramen at the L1-L2 level is noted bilaterally.
There is a postero-central disc herniation at the L5-S1 level indenting the traversing S1 nerve roots bilaterally. Slight facetal hypertrophy is noted at this level.
Posterior disc bulges with posterior peridiscal osteophytes are noted at the L3-L4 and L4-L5 levels.
The lumbar intervertebral discs show loss of water content.
The rest of the lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints are unremarkable.
The conus medullaris terminates at the D12-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 :
7.0 mm at L1-L2
12.0 mm at L2-L3
12.0 mm at L3-L4
11.0 mm at L4-L5
5.0 mm at L5-S1.
Screening T1 Weighted sagittal images of the dorsal spine reveal slight anterior wedging of the D11 vertebral body and central wedging of the D7 vertebral body, without change in signal intensity.
1. Wedging of the L2 vertebral body with altered signal of the L1, L2 and upper half of the L3 vertebral body and the L4 vertebral body with prevertebral, left paravertebral and anterior epidural soft tissue lesion as described is not specific for a single etiology. Tuberculous osteitis with pre and left paravertebral abscess/granulation tissue may be a likely possibility.
The possibility of a metastasis and round cell tumor may be considered in the differential diagnosis.
- 3 - Scan-00001
2. A postero-central disc herniation at the L5-S1 level indenting the traversing S1 nerve roots bilaterally with slight facetal hypertrophy and a tight canal at this level.