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Date : 00.00.00

Name of the Patient : Abc Xyz Cholmn / F / 19 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Dorsal Spine.

CLINICAL PROFILE :

C/O fever with chills and backache since 6 months.

EXAMINATION :

M.R.I of the dorsal spine was performed using the following parameters :

4 mm thick T1 Weighted and T2 Weighted sagittal images.

8 mm thick T1 Weighted and T2 Weighted axial images.

4 mm thick Fast Scan (T2 *) coronal images.

The lumbar spine was screened with 5 mm thick T1 Weighted sagittal images and the cervical spine was screened with 4 mm thick T1 Weighted sagittal images.

OBSERVATION :

The L5 vertebra appears to be sacralized. The D11 vertebra appears as marked on the film. Please correlate with plain radiographs.

Areas of hypointensity on the T1 Weighted images which turn hyperintense on the T2 Weighted images are seen to involve the D6 to D11 vertebral bodies and the right pedicles of the D7 to D10 vertebrae. There is a decrease in height of the D10 vertebral body with erosion of its superior surface. The D9-D10 disc shows a hyperintense signal on the T2 Weighted images suggestive of its involvement with erosion of its adjacent cortical endplates.
Scan-00004


There is a large soft tissue lesion which is hypointense with a hyperintense rim on the T1 Weighted images and turns hyperintense with a hypointense rim on the T2 Weighted images within the pre and paravertebral soft tissues over the D5-D6 to D11-D12 levels. This most likely represents an abscess.

Pleural effusion is noted on the right side.

The visualized dorsal vertebral bodies and intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The visualized dorsal spinal cord reveals normal signal intensity. There is no cord compression.

The conus medullaris terminates at the D12 level.

The screening images of the cervico-dorsal and the lumbo-sacral spine do not reveal any diagnostic feature of note.

IMPRESSION :

The MRI features are suggestive of a pathologic process involving the D6 to D11 vertebrae with a soft tissue lesion (most likely an abscess) extending over the D5-D6 to D11-D12 levels as described. This most likely represents an infective process like tuberculosis.

The possibility of this being a neoplastic process like a small cell tumor is less likely.
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