67-year-old male with history of HCC on radiation presenting with lower back pain. Evaluate for metastases or abscess.ANDERSON, STANLEY (DOB: 3/2/1949)PROVIDER/ATTENDING NAME: CHRAPEK, KRISTINE Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall alignment and height. The conus medullaris on sagittal imaging is grossly intact. There is abnormal marrow signal consisting of decreased T1 and increased T2/STIR signal with enhancement completely replacing the L3 vertebral body as well as the pedicles and to a lesser extent S1 and along the inferior endplate of L2. There is infiltration of the surrounding soft tissues around L3 with thickening and enhancement of the adjacent epidural space causing compression of the thecal sac with associated spinal canal stenosis at this level. There is infiltration of the fat along the neural foramina at L3-L4. Similarly there is infiltration of the fat surrounding the left S1 exiting nerve root.There is similar abnormal bone marrow signal of the right iliac bone.On review of the prior CTs, in retrospect there was mild low attenuation of the above vertebral bodies on prior study dated 11/30/2016 however the lesions cannot be detected on the more remote CT studies from 11/18/16, August and June 2016 and April 2011 suggesting a rapidly developing process.At L5-S1 there is broad-based disc bulge, ligamentum flavum thickening and mild facet hypertrophy. No significant compromise to spinal canal or neural foramina.At L4-5 there is broad-based disc bulge, ligamentum flavum thickening and mild facet hypertrophy. There is mild spinal canal stenosis. No significant neural foraminal stenosis.At L3-4 there is moderate spinal canal stenosis. No significant neural foraminal stenosis.At L2-3 there is mild broad-based bulging of the disc, ligamentum flavum thickening and mild facet hypertrophy. There is no significant spinal canal or neural foraminal stenosis.At L1-2 there is no significant compromise to spinal canal or neural foramina.
1.There are multiple infiltrating lesions the largest of which involves L3 which infiltrates and the surrounding musculature and into the adjacent L2 vertebral body along its left inferior aspect. There is extension into the spinal canal epidural space with associated narrowing of the spinal canal and moderate spinal canal stenosis. The lesion also infiltrates into the L3-4 neural foramina where it affects the exiting nerve roots. These appear to have rapidly progressed since the November 30 CT. These lesions could represent metastatic disease though the possibility the represent an infectious process such as tuberculosis cannot be excluded. Bone biopsy may be of further benefit if clinically indicated.2.There is an infiltrative lesion present in the left sacral alla which extends into the left S1 neural foramen. It is suspected to be of similar origin to the above described lesion.3.Another lesion is present within the right sacral alla and another one in the right iliac bone. These are also suspected to be of similar origin to the above described lesions.4.There is a lesion present within the liver which is not completely evaluated on this exam. Please refer to CT of the abdomen for further comments.5.Findings were discussed with the clinical service by phone on 12/29/2016 at 10:00 AM and the decision was made to proceed with bone biopsy which will be arranged today.Findings also discussed with the radiation oncology team Dr Haraf in person in the neuroradiology reading room.