sb/ke
Date : 00.00.00

Name of the Patient : Abc XyzD. Bholmn / F / 17 yrs.
Referred by : Dr. Abc Xyzndesha.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE with paresthesias since March 0000 which has increased since 3 months.
H/O fall in March 0000.

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 loss of normal lumbar lordosis. The L4 vertebral body appears hypointense on the T1 Weighted images and hyperintense on the T2 Weighted images. Erosion of the left lateral and posterior margins of the L4 body is noted. Break in the superior and inferior cortical endplate is also noted, to the left of the midline. The L3-L4 and L4-L5 intervertebral discs to the left of the midline appear more hyperintense on the T2 Weighted images.

There is seen an intermediate signal intensity soft tissue lesion on the T1 Weighted images in the left paravertebral region extending over the L3 and L4 vertebral levels. This lesion appears hyperintense on the T2 Weighted images. Extension into the anterior epidural space at these levels is also noted, with thecal sac compression. Encasement of the L4 nerve roots in the neural foramen at the L4-L5 level, bilaterally is also noted. The left psoas muscle is involved by the lesion.

The rest of the visualized 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-S2 level.
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The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

17.0 mm at L1-L2

15.0 mm at L2-L3

16.0 mm at L3-L4

14.0 mm at L4-L5

9.0 mm at L5-S1.

IMPRESSION :

Altered signal of the L4 vertebral body and the L3-L4 and L4-L5 intervertebral discs most likely represents osteitis with discitis, probably tuberculous in etiology. Left paravertebral and anterior epidural soft tissue lesion over the L3 and L4 vertebral levels represents an abscess/granulation tissue.

The possibility of a neoplasm is less likely.