ke/bv/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xlmn / M / 13 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Cervico-dorsal Spine.
CLINICAL PROFILE :
C/O neck pain and pain in the right paraspinal region upto shoulder since 2 months.
On AKT since 3 days.
EXAMINATION :
M.R.I of the cervico-dorsal spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and Fast Scan (T2 *) axial images.
OBSERVATION :
There is collapse of the D3 vertebral body. There is replacement of the normal marrow of the C6, C7, D1, D2, D3 and D4 vertebral bodies by hypointense areas on the T1 Weighted images. These are seen to turn heterogeneously hyperintense on the T2 Weighted images. There is a large pre and paravertebral soft tissue extension over the C4 to the D5 levels which is slightly hyperintense to the muscles on the T1 Weighted images and turns hyperintense on the T2 Weighted images. Few septae are noted within this lesion and this would represent abscess formation. Small anterior epidural extension is seen at the D3 and D4 levels with mild anterior compression of the cord on the right side.
The visualized dorsal and cervical spinal cord shows normal signal intensity.
The rest of the visualized cervico-dorsal vertebral bodies and the intervertebral discs show normal signal intensity. The joints of Luschka are unremarkable.
..2/.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
IMPRESSION :
In a known C/O tuberculous spine, the MRI features are suggestive of altered signal of the C6, C7, D1, D2, D3 and D4 vertebral bodies with a large pre and paravertebral soft tissue abscess over the C4 to the D5 levels and epidural extension as described.