sb/ke
Date : 00.00.00

Name of the Patient : Abc Xyzakash Goslmn / M / 35 yrs.
Referred by : Dr. Abc Xyz.
Examination : M.R.I. of the Lumbo-sacral Spine and
Sacrum.

CLINICAL PROFILE :

Operated for a lymphoma of the left S. I. joint on 00.00.00. Received 25 sittings of radiation and 6 cycles of chemotherapy. Still C/O pain in the LLE with paresthesias.

EXAMINATION :

M.R.I of the lumbo-sacral spine and sacrum was performed using the following parameters :

5 mm thick T1 Weighted and T2 Weighted sagittal images.

5 mm thick T2 Weighted axial images.

6 mm thick T1 Weighted and T2 Weighted axial images.

4 mm thick T1 Weighted and STIR coronal images.

OBSERVATION :

There is an ill-defined, hypointense signal on the T1 Weighted images in the marrow of the sacral ala, bilaterally, in the left half of the sacral segments and in the left iliac bone. This signal appears hyperintense on the T2 Weighted and STIR images. Erosion of the posterior margin of the left iliac bone and part of the sacral segments is noted.







There is an intermediate signal intensity soft tissue lesion on the T1 Weighted images anterior and posterior to the left sacro-iliac joint. This lesion appears hyperintense on the T2 Weighted and STIR images. Extension into the left lateral epidural space and into the upper sacral foramina is noted over the S1 to S3 sacral segments, with resultant encasement of the corresponding sacral nerve roots. The left S. I. joint is involved by the lesion.

The left gluteus maximus muscle shows a hyperintense signal on the T2 Weighted and STIR images. Atrophy of the left gluteus muscle is also noted.

The lower lumbar vertebrae, right half of sacral segments and visualized right iliac bone show fatty marrow changes, the sequelae of previous radiotherapy.

No significant discal herniation is noted in the lumbar region. The conus medullaris terminates at the L1 level.

The right S. I. joint is unremarkable.

IMPRESSION :

Altered signal involving the sacral segments and the left iliac bone as described most likely represents residual/recurrent lesion, in a known C/O lymphoma. Soft tissue extension is noted anterior and posterior to the left S. I. joint and into the left sacral foramina over the S1 to S3 segments with encasement of the corresponding sacral nerve roots. The patient is status post-operative and post-radiotherapy.

As compared to the previous CT Scan dated 00.00.00, there is a decrease in the soft tissue posterior to the left S. I. joint.