hs/ke/rg.
Date : 00.00.00

Name of the Patient : Abc XyzPlmn / F / 23 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE since 1 1/2 years. Also C/O loss of appetite/weight.

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 are areas of hypointensity on the T1 Weighted images which turn heterogeneously hyperintense on the T2 Weighted images within the L2, L4, L5 and S2 vertebral bodies. There is slight extension of the pathologic process into the prevertebral soft tissues on the left side at the L4 and L5 levels.

There appears to be an ulcer in the back at the L5 level. Areas of intermediate signal intensity on the T1 Weighted images are seen to extend from the ulcer into the interspinous soft tissues at the L4/L5 level. This is seen to communicate with a posterior epidural component at the L5 vertebral level. There is probable involvement of the adjacent spinous processes.

The cervico-dorsal spine was screened with 5 mm thick T1 Weighted sagittal images and 5 mm thick T2 Weighted axial images through the region of interest. Hypointense areas are seen to involve the D5, D6, D7, D9 and D10 vertebral bodies with extension of this pathologic process into the prevertebral soft tissues at the D5 level and over the D8 to the D10 levels.
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The rest of the visualized vertebrae in the spinal axis appear to be more hypointense than the normal on the T1 Weighted images (? preponderance of haematopoeitic marrow).

The lumbar intervertebral discs reveal normal signal intensity.

The conus medullaris terminates at the L1 level and the thecal sac terminates at the S1-S2 level.

IMPRESSION :

The MRI features are suggestive of a pathologic process involving the D5, D6, D7, D9, D10, L2, L4, L5 and S2 vertebral bodies with an ulcer in the back at the L5 level and epidural extension as described is not specific for a single etiology.

The differential diagnosis would include,

1. Infective processes (? tuberculosis).

2. Neoplastic process (? small cell tumor).