Case 35 - Discitis, Osteomyelitis

Dr. Yousem has provided the following report as a sample report for your reference. It does not match the case reviewed in the video.

Procedure: MRI LUMBAR SPINE WITHOUT AND WITH CONTRAST

INDICATION: History of polysubstance abuse, hepatitis C, L4-L5 osteomyelitis discitis, wheelchair dependence, presenting with 2 day history of worsening back pain. Concern for osteomyelitis.

COMPARISON: CRISP MRI lumbar spine report from 6/6/2020-images not available. Lumbar spine radiograph from 5/5/2014.

TECHNIQUE/PROTOCOL: Standard protocol lumbar spine pre and post contrast MRI performed.

CONTRAST: 8 mL Gadavist IV administered without acute adverse event. IV contrast was administered to improve disease detection and further define anatomy.

LUMBAR SPINE FINDINGS:

Alignment: Mild retrolisthesis L4 over L5 secondary to destructive intervertebral disc changes.

Spinal Cord and Cauda Equina: Crowding of the cauda equina nerve roots related to sever stenosis at L4-L5 as detailed below. Severe spinal canal stenosis at L4-L5 secondary to L4 retrolisthesis, and anterior epidural phlegmonous changes, and prominent posterior vertebral fat.

Conus: The conus terminates at approximately L1-L2.

Marrow Signal: Decreased T1 signal and increased T2/STIR signal within L4-L5 vertebral bodies with also note of associated enhancement on the postcontrast images.

Enhancement: Abnormal enhancement noted within the intervertebral disc space, prevertebral soft tissues, and the anterior epidural space at the L4-L5 level. Heterogeneous increased T2/STIR signal and enhancement within L5-S1 intervertebral disc.

Multiple nonenhancing areas are seen within the intervertebral disc space, measuring up to 1.3 cm., compatible with small abscess formations

Epidural Space: Enhancing T2/STIR hyperintense anterior epidural soft tissue at the L4-L5 level measuring approximately 0.8 cm in anterior dimension causing effacement of the CSF space with crowding of cauda equina roots. Phlegmonous changes extend into the bilateral lateral recesses causing severe bilateral neuroforaminal narrowing.

Vertebral Body Heights: Destructive erosions of vertebral bodies adjacent to L4-L5 disc space. Mild degenerative disc height loss at L5-S1.

Intervertebral Discs: Aggressive enhancing erosion of L4-L5 disc with severe disc expansion.

Disc Bulge or Herniation: Prominent L4-L5 disc expansion causing severe bilateral neural foraminal narrowing and severe canal stenosis. Moderate disc bulge and ligamentum flavum thickening at L5-S1 causing moderate spinal canal stenosis and moderate bilateral neuroforaminal narrowing. Mild disc bulge and ligamentum flavum thickening at L3-L4 causing mild spinal canal stenosis and mild bilateral neuroforaminal narrowing.

Prevertebral/Paraspinal Soft Tissues: T2/STIR heterogeneous enhancing prevertebral phlegmonous collection extending from L4 through L5-S1 intervertebral space measuring up to 0.8 cm in AP diameter, with mild elevation of the anterior longitudinal ligament, and apparent obliteration of fat planes between bilateral psoas muscles. Moderate edema noted within the paraspinal soft tissues extending from L1 through inferior sacral spine.

Visualized Surrounding Organs and Viscera: Unremarkable.

IMPRESSION:

1. L4-L5 discitis-osteomyelitis with prominent expansion of the intervertebral disc containing multiple nonenhancing loculations/abscesses measuring up to 1.3 cm. Phlegmonous formation with anterior epidural extension and resultant near complete effacement of CSF space, along with prominent posterior epidural fat, contributing to severe spinal canal stenosis at this level. The phlegmonous formation extends into the bilateral lateral recess and contributes to severe neural foraminal stenosis. Of note there is no prior cross-sectional imaging available for comparison.

2. Mild extension of the phlegmonous formation into the medial aspect of the bilateral psoas muscles with no evidence of abscess formation within the muscles.

3. Heterogeneous signal within L5-S1 intervertebral disc is indeterminate and recommend attention on follow-up imaging.

4. Multilevel degenerative disease, most prominent at L5-S1 with moderate bilateral neuroforaminal narrowing.