hs/ke
Date : 00.00.00
Name of the Patient : Abc Xyzra Tilmn / M / 30 yrs.
Referred by : Dr. Abc Xyzidya.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with tingling since 1 year.
H/O I & D done for abscess over the left gluteal region 6 months back with sinus discharge since then. On AKT since 3 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 sagittal images.
6 mm thick T1 Weighted and STIR coronal images.
7 mm thick T1 Weighted and T2 Weighted axial images.
OBSERVATION :
Areas of hypointensity on the T1 Weighted images which turn heterogeneously hyperintense on the T2 Weighted images are seen to involve the S1 to S4 vertebral bodies. There is extension of this pathologic process into the prevertebral soft tissues in the sacral region. This lesion is hypointense with a hyperintense rim on the T1 Weighted images and turn hyperintense with a hypointense rim on the T2 Weighted images images and most likely represents an abscess. Also seen is extension into the left puriformis and left gluteal muscles and into the right iliacus muscle.
The L5-S1 intervertebral disc is involved as is the L5 vertebral body.
- 2 - scan-00003
Hypointense areas on the T1 Weighted images which turn heterogeneously hyperintense on the T2 Weighted images are seen to involve the D11, D12, L1, L3 and L4 vertebral bodies. Also seen is extension into the left paravertebral soft tissues over the L3-L4 to L5-S1 level.
IMPRESSION :
The MRI features are suggestive of a pathologic process involving the sacrum and dorso-lumbar vertebrae with soft tissue extensions as described. This most likely represents an infective process like tuberculous (less likely to be a neoplastic prcess).