Date : 00.00.00
Name of the Patient : Abc Xyz lmn / F / 62 yrs.
Referred by : Dr. Abc Xyzl.
Examination : M.R.I. of the Dorso-lumbar Spine.
CLINICAL PROFILE :
Known C/O Potts spine detected in October 0000. On Rx since September 0000.
C/O weakness of BUE and BLE with bladder/bowel involvement.
H/O V.P. shunt done in January and February 0000.
M.R.I of the dorso-lumbar spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
6 mm thick T1 Weighted and T2 Weighted axial images.
SOME IMAGES SHOW PATIENT MOTION.
The MRI scan was compared to the previous scans dated 00.00.00 and 00.00.00 and the vertebral bodies were labelled accordingly.
The L2 and L3 vertebral bodies adjacent to the L2-L3 intervertebral disc appears hypointense on the T1 Weighted images and hyperintense on the T2 Weighted images. The L2-L3 intervertebral disc is not well-defined. Hyperintense signal is seen in the paravertebral soft tissue and the psoas muscle on the T2 Weighted images at the L3 level suggestive of extension of the pathologic process. Generalized bulge of the L2-L3 disc with peridiscal osteophyte is noted.
Small posterior disc bulges are noted at the L3-L4 and L4-L5 levels. Facetal hypertrophy is noted at the L3-L4 and L4-L5 levels.
The CSF within the thecal sac in the lower dorsal and lumbar regions appears slightly more hyperintense than normal on the T1 Weighted images. There is seen an intradural lesion in the upper dorsal region over the C7 to D4 vertebral levels anterior to the dorsal spinal cord. This lesion follows CSF signal and represents an intradural arachnoid cyst. The dorsal spinal cord is displaced posteriorly at these levels. The dorsal spinal cord at the D5, D6 and D7 levels shows a hyperintense signal on the T2 Weighted images suggesting cord edema/ischemia/gliosis.
There is probable evidence of surgical intervention in the dorsal spine over the D3 to D5 vertebral levels.
The dorsal intervertebral discs show loss of water content.
The rest of the visualized dorso-lumbar vertebral bodies show normal signal intensity.
The conus medullaris terminates at the D12-L1 level.
1. Altered signal of the L2 and L3 vertebral bodies and the L2-L3 intervertebral disc, most likely represents the sequelae of previous osteitis and discitis.
2. Small posterior disc bulges at the L3-L4 and L4-L5 levels.
3. Facetal hypertrophy at the L3-L4 and L4-L5 levels.
4. An intradural arachnoid cyst over the C7 to D4 vertebral levels with probable surgical intervention in the dorsal spinal canal over the D3 to D5 vertebral levels.
5. Altered signal of the dorsal spinal cord at the D5, D6 and D7 levels suggests cord edema/ischemia/gliosis.
6. Altered signal of the CSF in the lower dorsal and lumbar regions suggests arachnoiditis.