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sb/hs/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzi Maklmn / F / 80 yrs.
Referred by : Dr. Abc Xyzisheri.
Examination : M.R.I. of the Dorsal Spine.

CLINICAL PROFILE :

C/O backache since 2-3 months and weakness of BLE with bladder/bowel involvement since 3-4 days.

EXAMINATION :

M.R.I of the dorsal spine was performed using the following parameters :

5 mm thick T1 Weighted and T2 Weighted sagittal images.
6 mm thick T1 Weighted and T2 Weighted axial images.

The lumbar and cervico-dorsal regions were screened with 5 mm and 4 mm thick T1 Weighted sagittal images, respectively.

OBSERVATION :

The D2 and D3 vertebral bodies appear hypointense on the T1 Weighted images and hyperintense on the T2 Weighted images. Probable involvement of the D2-D3 intervertebral disc is noted. There is destruction of the left sided pedicles and transverse process of the D1 and D2 vertebrae. Involvement of the left costo-vertebral and costo-transverse joints at these levels is also noted. There is seen an intermediate signal intensity soft tissue mass lesion on the T1 Weighted images in the left paravertebral and posterior paraspinal region over the D2 and D3 vertebral levels. This lesion also appears hyperintense on the T2 Weighted images. There is extension into the left lateral and posterior epidural space over these levels with resultant cord compression. The dorsal spinal cord at these levels shows a hyperintense signal on the T2 Weighted images suggesting cord edema/ischemia/myelitis. Also seen is involvement of the left laminae and spinous processes of the D2 and D3 vertebrae.



There is anterior wedging of the D7 vertebral body. Hypointense areas on the T1 Weighted images which turn hyperintense on the T2 Weighted images are seen within its inferior aspect.

The rest of the visualized dorsal vertebral bodies show spotty fatty marrow changes suggesting osteoporosis. The rest of the intervertebral discs show loss of water content.

The conus medullaris terminates at the D12-L1 level.

Screening images of the cervical spine reveal degenerative changes at the C5-C6 level with osteoporotic changes in the vertebral bodies. Screening images of the lumbar spine reveal osteoporotic changes in the lumbar vertebrae.

IMPRESSION :

Altered signal of the D2 and D3 vertebrae and D2-D3 intervertebral disc suggests osteitis with discitis probably tuberculous in etiology. Left paravertebral and epidural soft tissue lesion may represent granulation tissue/abscess. Also seen is cord compression at the D2 and D3 levels.

The possibility of a neoplasm may be considered as a differential diagnosis though less likely.

Anterior wedging of the D7 vertebral body may be due to previous trauma.

The rest of the visualized vertebrae show osteoporotic changes.
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