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sb/hs/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Mlmn / F / 4 1/2 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Dorso-lumbar Spine.

CLINICAL PROFILE :

H/O being operated for a PNET in the lower dorsal cord and conus (D9-L1). Has received chemotherapy (4 cycles).
For follow up.

EXAMINATION :

M.R.I of the dorso-lumbar spine was performed using the following parameters :

4 mm thick T1 Weighted and T2 Weighted sagittal images.

5 mm thick T1 Weighted and T2 Weighted axial images.

After administration of contrast, 4 mm thick T1 Weighted sagittal (with fat saturation), 5 mm thick T1 Weighted axial images (with and without fat saturation) and 4 mm thick T1 Weighted sagittal images through the cervico-dorsal region were obtained.

OBSERVATION :

There is evidence H/O laminectomy over the D7 to L1 vertebral levels with post-operative changes in the soft tissues in the posterior dorso-lumbar region over these levels. Susceptibility artifacts are noted along the left sided laminae at the D10/D11 levels. The lower dorsal spinal cord at the D10 and D11 levels appears slightly atrophied. A CSF intensity lesion on all pulse sequences is noted within the dorsal spinal cord, posteriorly at the D10 and D10-D11 level. This may represent an area of myelomalacia/syrinx, most likely the sequelae of previous surgery.

An isointense (to normal cord) nodular lesion is noted along the anterior margin of the dorsal spinal cord at the D11-D12 level.


After administration of contrast, there are nodular enhancing lesions along the anterior and posterior margins of the lower dorsal spinal cord over the D10 to D12 vertebral levels.

T1 Weighted sagittal images of the cervico-dorsal spinal cord, after contrast administration, do not reveal abnormal enhancement on this study.

The visualized dorso-lumbar vertebral bodies and intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1 level.

IMPRESSION :

1. Post-operative/post-chemotherapy status.

2. Small enhancing nodules along the anterior and posterior margins of the lower dorsal spinal cord over D10 to D12 vertebral levels.

3. An area of myelomalacia/syrinx in the dorsal spinal cord, posteriorly at the D10 and D10-D11 level.

As compared to the previous MRI dated 00.00.0000, there is no significant change noted.





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    • Interventional Pain Procedure Templates
    • The Ultimate Guide to Rapid Reporting for FRCR 2B
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