Clinical question: Evaluate for discitis; E faecalis bacteremia with high CRP> 200. Signs and symptoms: Low back pain, severe pain in right groin radiating to buttocks. Pre and post enhancement lumbar MRI:Examination demonstrates abnormal increased T2 signal intensity of the disc space at L3-L4 level. There is also very extensive marrow signal changes of adjacent L3 and L4 vertebral bodies consistent with edema. There is significant enhancement of vertebral bodies of L3 and L4 however without detectable enhancement of the disc space. Findings are highly suggestive of discitis-osteomyelitis. Examination in addition demonstrate mild thickening and enhancement of epidural space without distinct cavity/abscess formation within the spinal canal. There is however extraosseous spread of infection into the bilateral psoas muscles with evidence of loculated cavity formation/abscess on the left extending from the disc level to beyond the field of exam in the pelvis on the left. A smaller localized right anterior lateral psoas abscess is also noted.Significant posterior ligamentum flavum hypertrophy at this level and degenerative changes anteriorly results in significant central spinal stenosis at this level.L3-L4 demonstrate moderate to advanced disc disease and extensive hypertrophic changes of posterior elements with resultant significant central spinal stenosis and mild to moderate right neural foraminal compromise.L4-L5 demonstrate advanced degenerative disc disease with significant loss of disc height and broad-based bulging disc which in combination with hypertrophic changes of posterior elements results in significant central spinal stenosis and mild to moderate bilateral neural foraminal compromise. There is also subtle T2 increase signal intensity of disc space at this level however without enhancement of the disc or adjacent endplates.L5-S1 demonstrate mild disc disease and mild facet and ligamentum flavum hypertrophy without spinal stenosis or neural foraminal compromise.Examination at T12-L1 and L1-L2 levels are unremarkable.On sagittal and axial T1 weighted images there is evidence of fatty signal intensity of L5 and terminale extending from L3-L4 disc level inferiorly and consistent with fatty filum. There is however normal termination of the cord at L1-L2 disc level. Visualized lower thoracic cord and conus demonstrate no signal abnormality or abnormal enhancement.
1.Signal abnormality of L3-L4 disc and with diffuse marrow signal abnormality and enhancement of adjacent vertebral bodies consistent with discitis-osteomyelitis. There is mild epidural thickening and enhancement without abscesses/cavity formation. There is bilateral paraspinal extension of inflammation/infection and with evidence of loculated psoas abscess formation on the left which extends from L4 inferiorly beyond the field of exam in the left pelvis. Smaller right-sided psoas abscess at the level of infection is also noted.. Extensive degenerative changes at this level also results in significant central spinal stenosis.2.Extensive degenerative changes at L2-L3 and L4-L5 levels results in significant central spinal stenosis.3.Neural foraminal compromise as detailed per level above.4.There is fatty filum terminale however with normal termination of the cord at L1-L2 level.5.No detectable abnormal signal or enhancement of the cord or the cauda equina.