Date : 00.00.00
Name of the Patient : Abc Xyzvi Ylmn / F / 55 yrs.
Referred by : Dr. Abc Xyztel.
Examination : M.R.I. of the Cervico-dorsal Spine.
CLINICAL PROFILE :
C/O weakness with wasting of BLE since 1 1/2 months.
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.
The lumbar spine was screened with 5 mm thick T2 Weighted sagittal images.
There is near complete collapse of the D4 vertebral body and anterior wedging of the D3 vertebral body with a kyphus at that level. The D3-D4 intervertebral disc is not well identified.
The D3, D4 and D5 vertebral bodies appear hypointense on the T1 Weighted images and heterogeneously hyperintense on the T2 Weighted images. There is prevertebral, paravertebral and anterior epidural soft tissue lesion extending over the D3 to D5 vertebral levels. This lesion is of intermediate signal on the T1 Weighted images and appears hyperintense on the T2 Weighted images. There is resultant cord compression over these levels. The dorsal spinal cord at these levels shows a hyperintense signal on the T2 Weighted images which suggest cord edema/ischemia.
The rest of the visualized cervico-dorsal vertebral bodies reveal normal signal intensity. The remaining cervico-dorsal intervertebral discs show loss of water content. The facet joints are unremarkable.
The T2 Weighted sagittal images of the lumbar spine shows a suspicious signal change in the S1 vertebral body. Small posterior disc herniations are noted in the lumbar region. Facetal hypertrophy is noted at the D11-D12 level on the right.
Nodular lesions are noted in the lung field on either side.
1. Near complete collapse of the D4 vertebral body, anterior wedging of the D3 vertebral body and altered signal of the D3, D4 and D5 vertebral bodies and the D3-D4 intervertebral disc as described most likely represents osteitis with discitis most likely tuberculous in etiology. Prevertebral, paravertebral and anterior epidural soft tissue lesion at D3 to D5 vertebral levels represents granulation tissue/abscess. There is resultant cord compression and cord signal alteration suggesting cord edema/ischemia.
Nodular lesions in both the lung fields also appear to be tuberculous in etiology.
The possibility of a neoplasm seems less likely.
2. Degenerative changes of the lumbar spine as described.