Date : 00.00.00
Name of the Patient : Abc XyzN. Vallmn / F / 25 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervico-dorsal Spine.
CLINICAL PROFILE :
C/O pain in the cervico-dorsal region with weakness of BLE with paresthesias.
M.R.I of the cervico-dorsal spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and T2 Weighted axial images.
There is near complete collapse of the D5 vertebral body. There is collapse with anterior wedging of the D4 vertebral body with a resultant kyphus.
Areas of hypointensity on the T1 Weighted images which turn heterogeneously hyperintense on the T2 Weighted images are seen to involve the D3, D4, D5 and D6 vertebral bodies, the D3, D4 and D5 pedicles and superior aspect of the D8 vertebral body on the right side. The D4-D5 and D5-D6 intervertebral discs are seen to be involved.
There is extension of this pathologic process into the pre and paravertebral soft tissues over the D2-D3 to D6-D7 levels. This lesion is 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 similar extension into the anterior epidural space over the D4 to D6 vertebral levels with compression upon the cord. The cord over these levels shows a hyperintense signal on the T2 Weighted images (iso to hypointense to normal cord on the T1 Weighted images) suggestive of cord edema/ischemia/myelitis.
There is probable encasement of the corresponding nerve roots over these levels.
There is involvement of the D3-D4, D4-D5 and D5-D6 costo-vertebral joints.
The rest of the visualized cervico-dorsal vertebral bodies and intervertebral discs are unremarkable.
The MRI features are suggestive of a pathologic process involving the D3, D4, D5, D6 and D8 vertebrae and the D4-D5 and D5-D6 intervertebral discs with extension into the soft tissues with cord compression and cord edema/ischemia/myelitis as described. This most likely represents an infective pathology like tuberculosis.
The possibility of this being a neoplastic process like a small cell tumor is less likely.