sb/bv
Date : 00.00.00

Name of the Patient : Abc Xyz lmn / M / 28 yrs.
Referred by : Dr. Abc Xyzrdiwala.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with numbness (below knee) since 1 week.
H/O fall 2 months ago.

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 and 5 mm thick T1 Weighted and T2 Weighted axial images.

OBSERVATION :

There is erosion of the spinous process of the L4 vertebra. In place is noted an intermediate signal intensity soft tissue mass lesion on the T1 Weighted images which appears hyperintense on the T2 Weighted images. This soft tissue lesion extends over the L4 and l5 vertebral levels on either side of midline. Extension of the soft tissue lesion into the posterior and right lateral epidural space over the L3 to S1 vertebral levels is noted with resultant compression and displacement of the thecal sac anterior to the left of the midline. The posterior soft tissue lesion and the epidural lesion show small pockets of altered signal which are slightly more hyperintense to the CSF on all pulse sequences, which most likely represents an abscess. Probable involvement of the laminae of L4 and L5 vertebrae is noted with involvement of the interspinous ligament. Encasement of the right sided L3, L4 and L5 nerve roots in the corresponding neural foramen is also noted.

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The lumbar vertebral bodies and the intervertebral discs reveal normal signal intensity. The facet joints and the visualized prevertebral soft tissues are unremarkable.

The D12 vertebral body shows a well-defined hypointense lesion on the T1 Weighted images to the left of the midline which appears hyperintense on the T2 Weighted images.

The conus medullaris terminates at the L2 level and the thecal sac terminates at the S2 level.

IMPRESSION :

Erosion of the spinous process of L4 with a soft tissue mass lesion, posteriorly over the L4 and L5 vertebral levels and in the posterior and right lateral epidural space with encasement of the L3, L4 and L5 nerve roots in the right neural foramina as described most likely represents an infective pathology, probably tuberculous in etiology. The soft tissue lesions described above represent granulation tissue/abscess. There is resultant thecal sac compression over the L3 to S1 vertebral levels.

Focal lesion at the D12 may represent osteitis.

The possibility of a neoplasm seems less likely.