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sb/ke/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzrajilmn / M / 36 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Dorsal Spine.

CLINICAL PROFILE :

H/O laminectomy from D2-D4 with excision of an ependymoma on 00.00.00.
C/O numbness in BLE with difficulty in walking since then.

EXAMINATION :

M.R.I of the dorsal spine was performed using the following parameters :

4 mm thick T1 Weighted and T2 Weighted sagittal images.

7 mm thick T1 Weighted and T2 Weighted axial images.

4 mm thick T2 Weighted sagittal images through the cervical region.

OBSERVATION :

There is evidence of laminectomy at the D3, D4 and D5 vertebral levels with post-operative changes in the posterior soft tissues at these levels.

There is loss of water content of the dorsal intervertebral discs.

There is an ill-marginated, intramedullary lesion within the upper dorsal spinal cord extending over the D2 to D5 vertebral levels. This lesion is of intermediate signal on the T1 Weighted images but appears heterogeneously hyperintense on the T2 Weighted images. Slight irregularity of the dorsal spinal cord at these levels is noted. Cystic/necrotic changes are also noted in the dorsal spinal cord, over these segment.




There is a hypointense lesion on the T1 Weighted images within the cervical spinal cord extending over the C2 to D1 and D6 to D8 vertebral levels. These lesions appear hyperintense on the T2 Weighted images and represent a syrinx/tumor related cyst. The cervico-dorsal spinal cord over the C2 to D1 vertebral levels appears increased in its transverse dimensions.

Small posterior disc bulges with posterior peridiscal osteophytes are noted in the cervical region.

The visualized dorsal vertebral bodies show normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

IMPRESSION :

1. Post-operative status.

2. Ill-marginated intramedullary mass lesion within the upper dorsal spinal cord over the D2 to D5 vertebral levels, as described, may either represent residual/recurrent tumor or post-operative changes. Cystic/necrotic areas are noted within this lesion. A tumor related cyst is noted in the cervical and dorsal spinal cords proximal and distal to this lesion.

A contrast enhanced scan would be worthwhile.

As compared to the previous MRI (study no:00007) dated 00.00.00, the tumor segment now appears ill-marginated. There is reduction in the size of the syrinx in the dorsal spinal cord, distal to the tumor segment. The proximal syrinx appears nearly unchanged.

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