Date : 00.00.00
Name of the Patient : Abc Xyzo Khatlmn / M / 40 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Dorsal Spine.
CLINICAL PROFILE :
C/O paraplegia with bladder/bowel involvement since 2 months.
H/O D4 laminectomy for Pott's spine 14 years back.
H/O decompressive dorsal laminectomy at D2-D3 on 00.00.00 for ossification of the ligamentum flavum causing spinal cord compression. Post-operatively patient has total paraplegia.
H/O spinal surgery on 00.00.00 (details not available).
M.R.I. of the dorsal spine was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and T2 Weighted axial images.
6 mm thick T1 Weighted coronal images.
There appears to be fusion of the D1 and D2 vertebral bodies with obliteration of the D1-D2 disc.
There are post-operative changes in the posterior soft tissues over the C6 to the D6 levels with laminectomy of the D1, D2, D3, D4 and D5 vertebral bodies.
The cervico-dorsal spinal cord over the C7 to atleast the D6 level is not well-defined. The cord appears smaller in diameter at the D3 and the C6 vertebral levels. Ill-defined hyperintense signal is visualized within the cervico-dorsal spinal cord suggestive of cord edema/ischemia/myelomalacia.
The rest of the visualized cervico-dorsal vertebral bodies and intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
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The MRI features are suggestive of :
1. Post-operative status.
2. Fusion of the D1 and D2 vertebral bodies with obliteration of the D1-D2 disc is probably the sequelae of previous infection.
3. Cord edema/ischemia/myelomalacia in the cervico-dorsal spinal cord over the C7 to atleast the D6 levels.
As compared to the previous MRI (scan no.00007) dated 00.00.00 the large collection
in the subcutaneous tissues posteriorly, is no longer identified on this study.