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hs/ke/nl/rg.

Name of the Patient : Abc XyzS. Lalmn / M / 26 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache.
L2-L3 decompression with placement of a bone graft was done on 00.00.00.
Patient is on AKT.

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.

5 mm thick T1 Weighted and T2 Weighted axial images.

OBSERVATION :

There is retroplacement of the L2 vertebra over the L3 vertebra with resultant indentation upon the thecal sac.

Areas of hypointensity on the T1 Weighted images which turn heterogeneously hyperintense on the T2 Weighted images are seen to involve the L2 and L3 vertebral bodies, the L3 pedicles bilaterally and the right L2 pedicle and the right transverse process and lamina of the L2 and L3 vertebrae.

The L2-L3 intervertebral disc is also involved by the pathologic process. Hypointense areas on the T2 Weighted images within this disc may represent the bone graft.






Hypointense areas on the T1 Weighted images which turn hyperintense on the T2 Weighted images are seen within the prevertebral and right paravertebral soft tissue (with involvement of the right psoas muscle) over the L2 and L3 vertebral levels. Similar signal characteristics are also seen within the right paraspinal soft tissues over the L1 to S1 vertebral levels with probable abscess formation over the L1 to L3 vertebral levels.

Also seen is extension into the anterior epidural space with indentation upon the thecal sac at the L2 and L3 vertebral levels.

There is a postero-central disc protrusion at the L5-S1 level and a posterior disc bulge at the L4-L5 level. The facet joints at these levels show mild degenerative changes. The intervertebral discs at these levels show mild 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 L1-L2 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 :

16.0 mm at L1-L2
13.0 mm at L3-L4
14.0 mm at L4-L5
11.0 mm at L5-S1.
..3/.












- 3 - Scan-00006


IMPRESSION :

In a known C/O tuberculosis of the spine the MRI features are suggestive of :

1. Post-operative status.

2. Involvement of the L2 and L3 vertebrae with soft tissue extension as described with retroplacement of the L2 vertebra over the L3 vertebra.

As compared to the previous MRI (study no:00005) dated 00.00.00, there is a decrease in the size of the right paravertebral abscess.

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