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15b - Answer: A patient with disorientation and a neck mass

David Yousem MBA, MD
David M Yousem, MBA, MD
Professor of Radiology, Vice Chairman and Associate Dean
Includes DICOM files

Learn more about this case by reading the case report below. Additional instruction is provided in the Case Summary section of the course.

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Case Report

HISTORY: Disorientation. Neck mass


TECHNIQUE: Axial CT scan images were performed through the brain and neck with multiplanar reconstructions of the axial CT data.


The ventricles and sulci are mildly dilated. There is minimal periventricular white matter hypodensity. There is no evidence of hemorrhage. There is no evidence of midline shift. There is no evidence of mass effect.

The visualized portions of the bones show hyperostosis frontalis interna.
There are no fractures seen. The paranasal sinuses are clear.

There is a small hyperdensity seen on series 3 image 139 near the right internal auditory canal. This measures approximately 1 cm. It is in the extra-axial space.

The postcontrast scans through the brain shows minimal enhancement of the area along the right anterior border of the internal auditory canal.

There is considerable soft tissue swelling over the left parotid gland and left side of the face as well as the left submandibular gland. The subcutaneous fat is edematous extending into the posterior triangle on the left side of the face.

The patient has an endotracheal tube and nasogastric tube.

In the chest there are bilateral pleural effusions as well as pulmonary infiltrates and there is paraspinal soft tissue thickening centered at the T2-3 level where there is erosion of the endplates as well as the disc.

There is fusion of the vertebral bodies at the C5-6 level.


  1. Unremarkable evaluation of the brain except for a 1 cm extra-axial enhancing lesion near the right internal auditory canal which could be a small meningioma. Follow-up with MRI.
  2. Probable T2-T3 discitis, osteomyelitis, and paraspinal abscess with extensive inflammation in the chest, oral cavity, and left side of the face. Mediastinitis also appears to be present as well as pulmonary infiltrates and pleural effusions.
  3. Please see chest CT results.


EXAM: MRI total spine with and without contrast.  
INDICATION: 73-year-old female who presents with sepsis and altered mental status with findings concerning for diskitis/osteomyelitis on prior CTs.  
TECHNIQUE: Multiplanar and multisequence MRI of the cervical, thoracic, and lumbar spine with and without administration of gadolinium-based contrast material.  
COMPARISON: CT C and L-spine with contrast dated 2/16/2017.  
There is a slight anterolisthesis of C3 on C4 and C4 on C5 with retrolisthesis of C5 on C6. There is a slight retrolisthesis of L1 on L2,  
and a slight anterolisthesis of L3 on L4 and L4 on L5. Alignment is otherwise maintained. No acute fractures or traumatic subluxations are appreciated.  
There is abnormal elevated T2 signal within the intervertebral disc space with associated endplate marrow change and extraosseous soft tissue component at the T2-3 and T12-L1 levels.  
Specifically, at T2-3, there is erosion of the associated endplates with marrow change. There is rim-enhancing purulent material centered in the T2-3 intervertebral disc space with marked extraosseous extension into the perivertebral soft tissues anteriorly and laterally bilaterally. The prevertebral abscesses appear to abut the posterior mediastinal structures including the esophagus. Inflammation extends into the bilateral T2-3 neural foramina.  There is extension into the ventral and dorsal epidural space at this level. Ventral epidural abscess involvement is  localized to the T2-3 level. However, dorsal epidural abscess involvement extends superiorly to the cervicothoracic junction and inferiorly to to the T7-8 level. There is ventral displacement of the thoracic cord at the T5-6 through T7-8 levels where dorsal epidural involvement is most pronounced. No definite elevated T2 signal within the thoracic cord at these levels although there is flattening and distortion of the dorsal cord  from T5 through T8 due to mass effect. There is mild canal narrowing  extending from the cervicothoracic junction to T4-5 level due to dorsal epidural involvement. There is also paraspinal soft tissue abscess formation alongside the spinous process of T5  involving the bilateral paraspinal musculature.  
At T12-L1, similar endplate erosive change are seen and purulent material within the intervertebral disc space is present. There is epidural abscess within the ventral epidural space at the T12 and L1 levels effacing the ventral epidural space and resulting in mild canal narrowing at these levels. There is extension of inflammation into the bilateral T11-12 through L1-2 neural foramina investing the exiting nerve roots at these levels respectively. No cord signal change appreciated.  
Additional levels of discitis osteomyelitis evidenced by endplate erosive change and marrow edema as well as elevated T2 signal within the disc space are present at T4-5 and L3-4 levels. At T4-5, there is extraosseous extension of inflammation into the left T4-5 neural foramen partially investing the exiting nerve root at this level. There is otherwise no extraosseous extension of inflammation  
appreciated at these levels.  
Psoas abscess present on the left at the L1-L4 levels arising from discitis osteomyelitis at T12-L1.  
At L1-2, there is a diffuse disc bulge and bilateral facet hypertrophy. There is mild canal narrowing. There is moderate to severe bilateral foraminal narrowing.  
At L2-3, there is a diffuse disc bulge and facet hypertrophy without canal narrowing. There is severe right and moderate left foraminal narrowing.  
At L3-4, there is a diffuse disc bulge and severe facet hypertrophy. There is severe canal and severe bilateral foraminal narrowing.  
At L4-5, there is a diffuse disc bulge and severe facet hypertrophy resulting in severe canal and moderate to severe bilateral foraminal  
At L5-S1, there is a diffuse disc bulge and severe facet hypertrophy. Mild canal narrowing with mild left and minimal right foraminal narrowing present.  
There is swelling and enlargement of the left submandibular gland in the left parotid gland as well as the soft tissues of the left neck. There is retropharyngeal edema likely reactive. There are loculated pleural effusions bilaterally.  


  1. Multilevel discitis/osteomyelitis at T2-T3 and T12-L1. At T2-3, there is bulky prevertebral abscess formation present as well as epidural abscess extension spanning craniocervical junction to T8 with ventral cord displacement without cord signal change due to dorsal epidural abscess formation T5-T8. Paraspinal soft tissue abscess spans the spinous process at the T5 level. At T12-L1, there  
    is ventral epidural abscess resulting in mild canal narrowing without cord signal change. Left psoas abscess  arises from inflammation at T12-L1.  
  2.  Additional levels of discitis osteomyelitis at T4-5 and L3-4.
  3. Enlargement and stranding of the left submandibular and parotid gland  
    suggests superimposed sialoadenitis.  
  4. Degenerative changes are most pronounced in the lumbar spine where  
    there is severe canal narrowing present at L3-4 and L4-5 levels.
  5. Loculated pleural effusions 

Case Challenge: Spine MRI Cases - I-MED Study

Content reviewed: May 12, 2022