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RAFIQ LS-spine

Mri reporting format

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24 views3 pages

RAFIQ LS-spine

Mri reporting format

Uploaded by

anilnewade
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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DR. V.M.GOVT.

MEDICAL COLLEGE &


S.C.S.M. GENERAL HOSPITAL,
SOLAPUR
Department Of radio diagnosis
MRI SECTION

NAME  RAFIQ BANGI


AGE/SEX  57 Y/ MALE
DATE  01/03/2024
REF. BY  DR. GOKUL SIR
CLINICAL HISTORY  LOWER BACKACHE , HIP PAIN, RADIATING TO BILATERAL
LOWER LIMB SINCE 2 MONTHS, OPERATED FOR RENAL CALCULI 2 MONTHS BACK.

MRI OF LUMBAR SPINE WITH WHOLE SPINE SCREENING

Scan Protocol:T1SE, T2 FSE, sagittal, T1SE, T2 FSE axial. COR STIR.

LUMBAR SPINE:
Spinal cord ends at lower end of L2 vertebra.
Variable dessication of L4-L5 and L5-S1 discs is seen.

Lumbar lordosis is maintained with normal alignment.

Conus medullaris and filum terminale appear normal.

Psoas muscles are normal.

Findings at specific level:

L1-L2: No disc bulge is seen. Bilateral traversing L2 and exiting L1 nerve roots appear normal.

L2-L3: No disc bulge is seen. Bilateral traversing L3 and exiting L2 nerve roots appear normal

L3-L4: Diffuse disc bulge seen at L3-L4 level indenting anterior thecal sac without spinal canal
compromise. Bilateral traversing L4 and exiting L3 nerve roots appear normal

L4-L5: Diffuse disc bulge seen at L4-L5 level indenting anterior thecal sac causing mild stenosis
of bilateral neural foramina. Bilateral traversing L5 and exiting L4 nerve roots appear normal.

L5-S1 Diffuse disc bulge seen at L5-S1 level indenting anterior thecal sac without spinal canal
compromise. Bilateral traversing S1 and exiting L5 nerve roots appear normal.
Area of altered signal intensity with soft tissue component noted involving S1 vertebral body
and right ala of sacrum. It appears hypo intense on T1 and hyperintense on STIR images.
Similar altered signal intensity is also noted at proximal shaft of left femur.
Spinal canal diameter in mm measures:-
L1-L2 L2-L3 L3-L4 L4-L5 L5-S1
14.4mm 12.5 mm 12.4mm 12.2 mm 9.9 mm

Screening Cervical Spine: Straitening of cervical spine.


Posterior disc bulge seen at C5-C6 level indenting anterior thecal sac (Spinal canal AP
diameter-6.2mm).

Screening Dorsal Spine: Unremarkable.

Spinal cord appears normal in signal intensity.

Visualized Pelvis:

Prostate appears bulky and measures 4.8 x 4 x 4.5 cm (AP x TR x CC), volume (43 CC).
Zonal differtiation of prostate is indistinct. Diffuse ill-defined T1 hypo intense T2 mixed signal
intense area measuring 4x3.7x3.1cm (APxTRxCC) noted predominantly involving left lobe of
prostate with displacement of prostatic urethra towards anteriorly and to right side with mild
proximal dilatation. There is capsular breech with involvement of left neurovascular bundle
and anterior wall of rectum. Laterally fat planes with obturator internus is lost on left side.
Postero laterally loss of fat plane with abutment of left levator ani sling noted. Right
neurovascular bundle appears unremarkable. Both seminal vesicle appears unremarkable.

Above imaging feature likely s/o malignant neoplastic etiology of prostate.

Suggest Dedicated MRI prostate contrast study.

IMPRESSION:-

 Altered signal intensity area with soft tissue component in S1 vertebra, right ala of
sacrum and left femoral shaft with morphology as described above.
 Bulky prostate with indistinct zonal differentiation and diffuse ill-defined area
involving peripheral zone on left side as described above.
Above imaging finding likely s/o spinal metastasis with primary likely Carcinoma of
prostate.
Suggest HPR/Lab correlation.

Suggest Dedicated MRI prostate contrast study And PSA.

DR HAFIZ DR. PREM DR AMIT PENDOR DR.AJEY BHAGWAT . DR. MUNDKAR C.B DR SHRUTI
JRIII SR ASSOCIATE PROFESSOR ASSOCIATE PROFESSOR LECTURER ASSISTANT PROFF.

MD MD M.D. DNB. MD

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