Case 4

This is an MRI lumbosacral spine study; there is high T2 and STIR signal centred on the L3/4 intervertebral disc, and L3 and L4 vertebral bodies. The L3/4 intervertebral disc and L4 vertebral body are completely collapsed and cannot be distinguished, replaced by phlegmon and necrotic bone. This extends superiorly to involve the lower half of L3 vertebral body, and inferiorly to the L4/5 disc causing superior herniation of the disc material.

The phlegmon / bony debris protrudes posteriorly into the epidural space and compresses the thecal sac at that level, postero-laterally to compress the L3/4 and L4/5 intervertebral foramina, as well as laterally to encroach on both psoas muscles.  

The post gadolinium series demonstrate marginal enhancement of the phlegmon collections. These findings represent advanced spondylodiscitis complicated by collections extending posteriorly into the epidural space and laterally into the psoas muscles.

I also note that there is generalised low T1 signal of the bone marrow replacing the normal high T1 signal, and marked splenomegaly – these findings indicate that the patient suffers from sickle cell anaemia. 

I would contact the referring physician urgently and convey the findings; urgent neurosurgical / spine surgery referral is warranted.