Date : 00.00.00
Name of the Patient : Abc Xyz C. Kulklmn / F / 59 yrs.
Referred by : Dr. Abc Xyzar.
Examination : M.R.I. of the Dorsal Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias 2 months ago.
Alleged H/O fall 2 months back.
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.
4 mm thick T1 Weighted coronal images.
There is seen a fairly large, approximately 7.5 x 7.0 x 7.5 cms sized heterogeneous signal intensity mass lesion in the right paravertebral region extending over the D4 to D8 vertebral levels. This lesion is predominantly of intermediate signal on the T1 Weighted images and turns predominantly hyperintense on the T2 Weighted images. Focal hypointense areas are noted within this lesion on all the pulse sequences.
There is erosion of the right lateral margin, right pedicle and transverse process and the right lamina of the D6 vertebra with extension of the lesion into the epidural space on the right and posteriorly over the D5-D6 disc level to the D6-D7 disc level. There is resultant cord compression and displacement of the dorsal spinal cord anteriorly and to the left over these levels. The dorsal spinal cord at these levels shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images suggesting cord edema/ischemia. The costo-vertebral, costo-transverse joints and the posterior segment of the right sixth rib are also not well identified. Slight extension of the mass lesion into the posterior paraspinal muscles on the right is also noted.
The D6 vertebral body appears hypointense on the T1 Weighted images and hyperintense on the T2 Weighted images. Minimal forward translation of the D6 over D7 vertebra is noted. The D5-D6 and D6-D7 intervertebral discs are unremarkable.
Facetal hypertrophy is noted at the D9-D10 and D10-D11 levels with effacement of the posterior CSF space. Small postero-central protruded discs are noted at the D12-L1 and L1-L2 levels.
The rest of the visualized dorsal vertebral bodies show spotty fatty marrow changes. Some of the dorsal intervertebral discs show loss of water content. The remaining facet joints are unremarkable.
The conus medullaris terminates at the L1-L2 level.
1. A fairly large, approximately 7.5 x 7.0 x 7.5 cms sized heterogeneous signal intensity mass lesion in the right paravertebral region extending over the D4 to D8 vertebral levels, with extension into the spinal canal as described, most likely represents a nerve sheath tumor. There is resultant cord compression and cord signal alteration over the D5-D6 to D6-D7 disc levels.
2. Facetal hypertrophy at the D9-D10 and D10-D11 levels and small postero-central disc protrusions at the D12-L1 and L1-L2 levels.
As compared to the previous CT Scan dated 00.00.00, there is an increase in the size of the lesion.