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hs/sb/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz Rlmn / F / 13 yrs.
Referred by : Dr. Abc Xyzidhwa.
Examination : M.R.I. of the Dorsal Spine.

CLINICAL PROFILE :

Past H/O tetanus, tetonic spasms and subsequent paraplegia.
Decompression laminectomy was done on 00.00.00.

EXAMINATION :

M.R.I of the dorso-lumbar 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.

OBSERVATION :

There is near complete collapse of the D5 vertebral body with angular kyphus at that level. The D5 body is not well-identified.

There are post-operative changes in the posterior soft tissues over the D2-D3 to D7 levels with laminectomy of the D3, D4 and D5 vertebrae.

There is a posterior peridiscal osteophyte at the postero-inferior margin of D4 body. The D4 and D6 vertebral bodies show areas which are isointense to fat on all the pulse sequences. The costo-vertebral joint at the D5 on the left shows hypertrophic degenerative changes. The spinal cord at the D5 to D7 levels shows a hyperintense signal on the T2 Weighted images which is iso to hypointense to normal cord on the T1 Weighted images and is suggestive of cord ischemia/myelomalacia/gliosis. The cord is thinned out over these levels.
Scan-00002


A small hypointense area is noted within the dorsal spinal cord at the D3-D4 level on the T1 Weighted images which turns hyperintense on the T2 Weighted images and may represent a cystic area.

The D4-D5 and D5-D6 intervertebral discs are not well identified separately.

The rest of the visualized dorso-lumbar vertebral bodies show normal signal intensity. The facet joints are unremarkable.

IMPRESSION :

1. Post-operative status.

2. Near complete collapse of the D5 vertebral body with angular kyphus at that level. This may be post-traumatic (post-tetanus), as the histopathology report did not suggest infective osteitis.

3. Thinning of the cord with altered signal over the D5 to D7 levels may suggest myelomalacia.

As compared to the previous MRI (study no:0000) dated 00.00.00, the cord appears to be smaller in size on the present study.



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