Date : 00.00.00
Name of the Patient : Abc XyzMerclmn / F / 79 yrs.
Referred by : Dr. Abc Xyzmpat.
Examination : M.R.I. of the Dorso-lumbar Spine.
CLINICAL PROFILE :
C/O backache with difficulty in walking since 1 month. H/O spinal surgery on 00.00.00 with weakness of BLE and bladder/bowel involvement.
M.R.I of the dorso-lumbar 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 are still seen post-operative changes in the right paravertebral region over atleast the D7 to D11 levels.
Areas of hypointensity on the T1 Weighted images which turn heterogeneously hyperintense on the T2 Weighted images are seen to involve the D10 and D11 vertebral bodies and pedicles. The D10-D11 intervertebral disc is seen to be involved with erosion of the adjacent cortical endplates.
There is extension of this pathologic process into the anterior epidural space at the D10 and D11 vertebral levels with mild cord compression. There is slight extension of the soft tissue into the prevertebral region over these levels.
There is a large right paravertebral soft tissue lesion seen over the D7 to the D11 levels with absence of the posterior segments of the D10, D9, D8 and the D7 ribs on the right side and probably the right transverse processes of the D7, D8 and D9 vertebrae. This lesion shows a hypointense signal as compared to fat on the T1 Weighted images and is heterogeneously hyperintense on the T2 Weighted images posteriorly and is hyperintense in the anterior portion.
The spinal cord over D10 to the tip of the conus medullaris shows a hyperintense signal on the T2 Weighted images which is iso to hypointense to normal cord on the T1 Weighted images, suggestive of cord edema/ischemia.
Left pleural collection is also noted.
A small well-defined area of hyperintensity on all the pulse sequences is seen within the postero-superior aspect of the D9 vertebral body and this would represent a hemangioma. The rest of the visualized dorsal vertebral bodies show areas of fatty replacement of normal marrow suggestive of osteoporosis.
A Schmorls node is seen in the superior surface of the D9 vertebral body.
The rest of the dorsal intervertebral discs show loss of water content.
1. Post-operative status.
2. Altered cord signal over the D10 to the tip of the conus medullaris most likely represents cord edema/ischemia.
- 3 - Scan-00004
3. Reduction in the anterior epidural lesion at the D10 and D11 vertebral levels as compared to the previous MRI study (scan no.00006).
4. Right paravertebral soft tissue lesion over the D7 to the D11 levels with left pleural collection as described is the sequelae of previous surgery.
As compared to the previous MRI (study no:00006) dated 00.00.00 :
1. There is reduction in the post-operative changes in the right paravertebral region.
2. Part of the D10 and D11 vertebral bodies show fatty marrow changes, suggesting a healing process.
3. Minimal reduction in size of the anterior epidural lesion at the D10 and D11 vertebral levels.
4. No significant change in the cord signal alteration over D10 to the tip of conus.