Date : 00.00.00
Name of the Patient : Abc Xyzai G. Sanlmn / F / 60 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Dorsal Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since 2 months. Also C/O gait imbalance.
H/O fall prior to this.
To r/o tubercle spine.
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.
There is a mild right postero-lateral disc bulge at the D11-D12 level with peridiscal osteophytes and antero-lateral indentation of the thecal sac at this level.
A left postero-lateral disc herniation is seen at the D8-D9 level.
A small posterior disc bulge is noted at the D12-L1 level.
Schmorls nodes are seen in the inferior aspect of the D7 vertebra.
The dorsal intervertebral discs show loss of water content.
The dorsal vertebral bodies reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
- 2 -
The dorsal spinal cord reveals normal signal intensity.
The conus medullaris terminates at the L1 level.
A small well-circumscribed lesion which is hyperintense to muscle
on the T1 Weighted and T2 Weighted images in the posterior aspect of the right lung at the D8/D9 levels (scans 108.16, 106.16). This may represent a granuloma or metastasis and would require further evaluation.
The cervico-dorsal spine was screened with 5 mm thick T2 Weighted sagittal images and does not reveal any significant feature of note. Mild ligamentum flavum hypertrophy is seen at the C6 level. Small posterior peridiscal osteophytes are seen in the cervical spine.
The MRI features are suggestive of :
1. Mild right postero-lateral disc bulge at the D11-D12 level with peridiscal osteophytes at this level.
2. Left postero-lateral disc herniation at the D8-D9 level.
3. A small posterior disc bulge at the D12-L1 level.
4. A small well-circumscribed lesion in the posterior aspect of the right lung at the D8/D9 levels may represent a granuloma or metastasis and would require further evaluation.