Date : 00.00.00
Name of the Patient : Abc Xyzn Mlmn / F / 25 yrs.
Referred by : Dr. Abc Xyzar.
Examination : M.R.I. of the Dorso-lumbar Spine.
CLINICAL PROFILE :
C/O backache since 6 months with paresthesias since 2 1/2 months and fever.
M.R.I of the dorso-lumbar spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
6 mm thick T1 Weighted and T2 Weighted axial images.
There is collapse of the D10 vertebral body. Areas of hypointensity on the T1 Weighted images which turn hyperintense on the T2 Weighted images are seen to involve the D7, D10 and D11 vertebral bodies and the D10 and D11 pedicles bilaterally. The D10-D11 intervertebral disc is also seen to be involved.
There is extension of this pathologic process into the anterior epidural space with resultant cord compression over the D9-D10 to the D11-D12 level. The cord over these levels shows a hyperintense signal on the T2 Weighted images suggestive of cord edema/ischemia/myelitis. Also seen is extension into the pre and paravertebral soft tissues over these levels.
There is encroachment of this pathologic process into the D10-D11 neural foramina bilaterally and into the right neural foramen at the D11-D12 level.
There is involvement of the costo-vertebral joints bilaterally at the D10 level and on the right side at the D11 level.
Note is made of a right sided pleural effusion.
A postero-central disc herniation with peridiscal osteophytes is seen to indent the thecal sac at the D12-L1 level.
The rest of the visualized dorso-lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints are unremarkable.
The cervico-dorsal and the lumbo-sacral spines were screened with
4 mm thick and 5 mm thick T1 Weighted sagittal images respectively. Hypointense areas are seen to involve the C3, C4, L3 and S1 vertebral bodies. The L5 vertebra is probably sacralized. Please correlate with plain radiographs.
The MRI features are suggestive of :
1. Probable sacralization of the L5 vertebra. Please correlate with plain radiographs.
2. A pathologic process involving the D10 and D11 vertebral bodies and the D10-D11 intervertebral disc with cord compression and cord edema/ischemia/myelitis over these levels with soft tissue extensions as described. This most likely represents an infective etiology like tuberculosis.
The possibility of this being a neoplastic process like a small cell tumor is less likely.
Also seen is involvement of the D7, C3, C4, L3 and S1 vertebral bodies by this pathologic process.