Date : 00.00.00
Name of the Patient : Abc Xyz Triplmn / M / 30 yrs.
Referred by : Dr. Abc Xyzchale.
Examination : M.R.I. of the Dorsal Spine.
CLINICAL PROFILE :
C/O weakness of BLE since November 0000 for which discoidectomy was done at C4-C5 and C5-C6 levels on 00.00.00. Subsequently developed fever and loose motions with paraplegia and swelling of BLE (right more than left).
M.R.I of the dorsal spine was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted sagittal images.
8 mm thick T1 Weighted and T2 Weighted axial images.
The lumbar and cervical spines were screened with 5 mm thick T1 Weighted sagittal images and 5 mm thick T2 Weighted sagittal images, respectively.
The dorsal spinal cord over atleast the D5 to D11 vertebral levels shows an ill-defined, hyperintense signal on the T2 Weighted images which appears iso to hypointense to normal cord on the T1 Weighted images. This signal is predominantly involving the posterior columns.
The visualized dorsal intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The visualized dorsal, lumbar and cervical vertebrae reveal hypointense marrow signal on the T1 Weighted images as compared to normal which suggests excess of hematopoietic marrow.
There is no cord compression.
The conus medullaris terminates at the L1 level.
Consolidation is noted in the visualized lung fields on either side.
Screening images of the lumbar spine reveal a distended urinary bladder without any obvious spinal lesion.
Screening images of the cervical spine reveal evidence of discoidectomy at the C6-C7 and C7-D1 levels. Altered cord signal is noted upto the D1 vertebral level.
1. Altered signal in the dorsal spinal cord over atleast the D1 to D11 vertebral levels as described is not specific for a single etiology. These changes may suggest cord demyelination/edema/ischemia/myelitis/gliotic changes.
Subacute combined degeneration should be ruled out.
2. The patient is status post-operative in the cervical region.
3. Consolidation is noted in the lower zones of both the lungs.