Date : 00.00.00
Name of the Patient : Abc Xyzv Tlmn / M / 21 yrs.
Referred by : Dr. Abc Xyztel.
Examination : M.R.I. of the Dorsal Spine.
CLINICAL PROFILE :
H/O dog bite on 00.00.00, Received ARV (last dose 7 days back).
C/O backache since 00.00.00 with weakness of BLE and bladder/bowel involvement since 3 days.
M.R.I of the dorsal spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
10 mm thick T1 Weighted and T2 Weighted axial images.
There is an increase in the diameter of the dorsal spinal cord. There is a hyperintense signal on the T2 Weighted images in the dorsal spinal cord, centrally extending over the D2 vertebral level upto the conus medullaris. This lesion appears hypointense to normal cord on the T1 Weighted images. Slight effacement of the CSF space around the dorsal cord is noted.
The D8-D9, D9-D10 and D10-D11 facet joints show hypertrophic changes.
The visualized dorsal vertebral bodies and intervertebral discs reveal normal signal intensity. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1 level.
Screening T2 Weighted sagittal images of the cervical spine, reveal similar signal intensity changes in the cervical cord over the C2 to C6 vertebral levels with slight swelling of the cervical cord over these levels.
Swelling of the cervical and dorsal spinal cords with altered signal centrally, as described, most likely represents an immune mediated myelitis/demyelinating lesion in the given clinical setting.