Date : 00.00.00
Name of the Patient : Abc Xyz Shlmn / F / 18 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
Previous MRI s/o a tuberculous spine involving the C5, C6 and C7 vertebrae. On AKT since February 0000.
For follow up.
M.R.I of the cervical spine was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and Fast Scan (T2 *) axial images.
There is still seen an ill-defined hypointense signal on the T1 Weighted images involving the body of the C6 vertebra and which appears hyperintense on the T2 Weighted and Fast Scan (T2 *) images. The C6-C7 intervertebral disc appears hyperintense on the T2 Weighted images. The C5 and the right half of the C7 vertebral bodies show evidence of fatty marrow changes.
Soft tissue lesion is still identified in the right neural foramen at the C4-C5, C5-C6 and C6-C7 levels. Minimal soft tissue lesion is also noted in the right paravertebral region over the C5-C6 to the C6-C7 levels and in the posterior paraspinal soft tissues on the right at the C2 and C3 vertebral levels.
Multiple, subcentimeter lymphnodes are noted deep to the sternocleidomastoid muscles bilaterally.
The rest of the cervical intervertebral discs show slight loss of water content.
The rest of cervical vertebral bodies show normal signal intensity. The joints of Luschka are unremarkable.
The cervical spinal cord shows normal signal intensity.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
1. Altered signal of the C6 vertebral body and the C6-C7 intervertebral disc may suggest residual osteitis/discitis, in the given clinical setting.
Fatty marrow changes in the C5 and right half of the C7 vertebral bodies may suggest resolving/resolved osteitis.
2. Soft tissue lesion in the right neural foramen at the C4-C5, C5-C6 and C6-C7 levels and minimal soft tissue lesion in the right paravertebral region over the C5-C6 to C6-C7 levels and in the posterior paraspinal soft tissues on the right at the C2 and C3 vertebral levels may represent residual granulation tissue.
As compared to the previous MRI (study no.00006) dated 00.00.00, there is significant resolution of the paravertebral, paraspinal and epidural soft tissue lesion and evidence of resolving osteitis in the cervical vertebral
bodies as described above.