sb/hs/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyz B. Anlmn / F / 20 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE since 4 months.

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.
7 mm thick T1 Weighted and T2 Weighted axial images.
6 mm thick T1 Weighted coronal images.

OBSERVATION :

There is partial collapse of the L5 vertebral body. The L3 to S1 vertebral bodies appear hypointense on the T1 Weighted images and hyperintense on the T2 Weighted images. The L4-L5 intervertebral disc is reduced in height and is also involved by the pathology. A kyphus is noted at the L4-L5 level. Erosion of the left pedicle and transverse process of the L5 vertebra is noted.

There is seen a fairly large, intermediate signal intensity mass lesion on the T1 Weighted images in the prevertebral and right paravertebral soft tissues extending over the L3 to the S2 vertebral levels and in the left paravertebral region extending over the L3 vertebral level, into the pelvis along the left lateral pelvic wall. This lesion appears hyperintense on the T2 Weighted images. Multiple septae are noted within this lesion. The distal psoas muscles are involved by this lesion. Minimal extension of the soft tissue lesion into the anterior epidural space at the L4-L5 level is noted, with encasement of the left L5 nerve root in the left neural foramen at the L5-S1 level.



A postero-central protruded disc with a peridiscal osteophyte is noted at the D11-D12 level.

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 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 :

18.0 mm at L1-L2
20.0 mm at L2-L3
19.0 mm at L3-L4
13.0 mm at L4-L5
13.0 mm at L5-S1.

IMPRESSION :

Altered signal of the L3 to S2 vertebral bodies and the L4-L5 intervertebral disc as described, most likely represents osteitis with discitis, probably tuberculous in etiology. Prevertebral and paravertebral soft tissue lesion represents an abscess. The left sided psoas abscess is seen to extend into the pelvis.