Date : 00.00.00
Name of the Patient : Abc Xyz Salmn / F / 19 yrs.
Referred by : Dr. Abc Xyztel.
Examination : M.R.I. of the Dorsal Spine.
CLINICAL PROFILE :
C/O backache with fever since 4 months with weakness of BLE since 6-7 days.
M.R.I of the dorsal 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 near complete collapse of the D5 vertebral body. Also seen is anterior wedging of the D4 vertebral body.
Areas of hypointensity on the T1 Weighted images which turn heterogeneously hyperintense on the T2 Weighted images are seen to involve the D1 to the D7 vertebral bodies and the pedicles of the D3, D4 and D5 vertebrae. The D10 vertebral body also shows subtle hypointense signal on the T1 Weighted images. There is also involvement of the D4-D5 and D5-D6 intervertebral discs.
There is extension of this pathologic process into the anterior epidural space over the D3 to D6 vertebral levels with resultant cord compression. The cord over these levels shows a hyperintense signal on the T2 Weighted images suggestive of cord edema/ischemia/myelitis.
This pathologic process is also seen to extend into the pre and paravertebral soft tissues over the D1 to the D7 vertebral levels. This lesion is seen to be hypointense with a hyperintense rim on the T1 Weighted images and hyperintense with a hypointense rim on the T2 Weighted images and most likely represents an abscess. Also seen is involvement of the costo-vertebral and costo-transverse joints at the D4, D5 and D6 vertebral levels.
The rest of the visualized dorsal vertebral bodies and intervertebral discs reveal normal signal intensity. The facet joints are unremarkable.
The lumbo-sacral spine was screened with 4 mm thick T1 Weighted sagittal images and is unremarkable.
The MRI features are suggestive of a pathologic process involving the D1 to the D7 vertebral bodies and D4-D5 and D5-D6 intervertebral disc with extensions and cord edema/isclmn / Myelitis 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.