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PROVISIONAL REPORT
Name of the Patient : Abc Xyzlmn / F / 26 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 4-5 months.
Alleged H/O fall.
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 replacement of the normal marrow of the L3 and the L4 vertebral bodies by hypointense areas on the T1 Weighted images. These are seen to turn heterogeneously hyperintense on the T2 Weighted images. There is minimal prevertebral soft tissue extension and extension into the psoas muscles bilaterally, left more than right over the L3 to the L5 vertebral levels. This is hypointense to the normal muscle on the T1 Weighted images and turns hyperintense on the T2 Weighted images and would represent an abscess.
A small posterior disc bulge with peridiscal osteophytes is seen at the L3-L4 and L4-L5 levels with anterior indentation of the thecal sac. The L3-L4 and L4-L5 intervertebral discs show loss of water content.
Schmorls nodes are seen in the lumbar region.
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- 2 - Scan-00003
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints are unremarkable.
The conus medullaris terminates at the L1-L2 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 :
20.0 mm at L1-L2
19.0 mm at L2-L3
18.0 mm at L3-L4
17.0 mm at L4-L5
15.0 mm at L5-S1.
IMPRESSION :
The MRI features are suggestive of :
1. A granulomatous infective process involving the L3 and L4 vertebral bodies with soft tissue extensions and abscess formation as described. This most likely represents tuberculosis.
The possibility of this being a neoplastic process like a round cell tumor is less likely.
2. A small posterior disc bulge with peridiscal osteophytes at the L3-L4 and L4-L5 levels.
Please send the films back for the final report.
Thanks for the reference.