ke/sb
Date : 00.00.00

Name of the Patient : Abc XyzSlmn / M / 35 yrs.
Referred by : Dr. Abc Xyztrak.
Examination : M.R.I. of the Dorsal Spine.

CLINICAL PROFILE :

Known C/O disseminated TB (chest, brain and spine) detected in December 0000. Received AKT for 3 years. Past H/O progressive paraplegia in April 0000.
Now C/O backache with residual paraplegia.

EXAMINATION :

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.

OBSERVATION :

The dorsal spinal cord appears atrophic and shows a hypointense signal from the D3 level downwards upto the conus-cauda, centrally on the T1 Weighted images. This lesion is seen to turn hyperintense on the T2 Weighted images and represents a syrinx. Multiple septae are noted within the syrinx. The margins of the dorsal spinal cord appears irregular which would be suggestive of arachnoiditis.

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

The conus medullaris terminates at the L1-L2 level.

The cervical spine was screened with 5 mm thick T2 Weighted sagittal images, which shows small posterior disc bulges at the C4-C5 and C5-C6 levels.

IMPRESSION :

The MRI features are suggestive of a syrinx over the D3 level downwards upto the conus-cauda as described, with irregular margins of the dorsal spinal cord suggestive of previous arachnoiditis.