Date : 00.00.00
Name of the Patient : Abc XyzK. Dlmn / F / 45 yrs.
Referred by : Dr. Abc Xyzo / Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Dorso-lumbar Spine.
CLINICAL PROFILE :
H/O left sided mastectomy done in 0000 for carcinoma breast, after which patient recovered.
Recurred in November 0000, Received radiotherapy - 32 sittings.
On AKT since 3 months for pulmonary kochs (AFB +ve in sputum).
C/O gait imbalance with bladder involvement since 15 days.
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.
There is seen an intermediate signal intensity soft tissue lesion on the T1 Weighted images in the posterior epidural space at the D8 and D9 vertebral levels. This lesion appears hyperintense on the T2 Weighted images. There is resultant anterior displacement and compression of the dorsal spinal cord at these levels. The dorsal spinal cord shows a hyperintense signal on the T2 Weighted images at the D8 and D9 vertebral levels, suggesting cord edema/ischemia. Probable involvement of the laminae of D8 and D9 is noted.
There is slight loss of water content of the L5-S1 intervertebral disc.
Minimal posterior disc bulges are noted at the L3-L4 and L4-L5 levels.
The visualized dorsal and lumbar vertebral bodies show spotty fatty marrow changes.
The remaining visualized intervertebral discs show normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
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The conus medullaris terminates at the L1 level and the thecal sac terminates at the S1 level.
Incidentally noted is a left sided pleural effusion and a soft tissue lesion in the base of the left lung.
Soft tissue lesion in the posterior epidural space at the D8 and D9 vertebral levels with cord compression and cord signal alteration , is not specific for a single etiology.
In a known C/O pulmonary tuberculosis this may represent tuberculous granulation tissue/abscess.
However, this is less likely to represent a metastatic deposit.
Soft tissue lesion in the base of the left lung with left pleural effusion may be inflammatory in etiology, in view of the AFB positive in sputum or may be due to metastasis.