sb/hs/nl/nl
Date : 00.00.0000
Name of the Patient : Abc Xyza Glmn / F / 21 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Sacro-iliac Joints.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE with paresthesias.
EXAMINATION :
M.R.I of the sacro-iliac joints was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted (with fat saturation) axial images.
5 mm thick T1 Weighted and STIR coronal images.
OBSERVATION :
There is an ill-defined, hyperintense signal on the T2 Weighted and STIR images in the right iliac bone adjacent to the right sacro-iliac joint. Similar signal change but to a much lesser degree is noted in the sacrum, on the right, antero-inferiorly. This signal appears hypointense to normal marrow on the T1 Weighted images. The cortical margin of the right iliac bone adjacent to the right sacro-iliac joint is not well-defined. Slight widening of the right sacro-iliac joint space, anteriorly, is noted, when compared to the left with a hyperintense signal on the T2 Weighted and STIR images within the joint space, suggesting a small right sacro-iliac joint effusion. There is also a hyperintense signal on the T2 Weighted and STIR images around the margins of the right sacro-iliac joint deep to the iliacus and psoas muscles which may be due to reactive inflammation. No obvious soft tissue mass lesion is identified around the right sacro-iliac joint.
The visualized left sacro-iliac joint is unremarkable.
The uterus appears slightly bulky (patient is post-partum). There are no obviously enlarged pelvic lympnodes identified.
The lumbo-sacral spine was screened with 5 mm thick T1 Weighted sagittal images. There is seen an approximately 1.5 cm diameter sized hyperintense lesion on the STIR images in the L3 vertebral body on the left, which appears faintly iso to hypointense to normal on the T1 Weighted images. This lesion most likely represents a hemangioma (se/im: 105.4, 5, 106.4,5, 107.3,4)
IMPRESSION :
Altered signal in the right iliac bone adjacent to the right sacro-iliac joint and to a much lesser extent in the sacrum, anteriorly, as described is not specific for a single etiology. These changes most likely suggest a right sided, infective/inflammatory sacro-ilitis. Minimal fluid is noted in the right sacro-iliac joint, anteriorly, with reactive, periarticular, inflammatory changes.
The possibility of this lesion representing a neoplasm seems less likely.
Focal lesion in the L3 vertebral body to the left, is most likely a vertebral body hemangioma.