Date : 00.00.00
Name of the Patient : Abc XyzMlmn / M / 70 yrs.
Referred by : Dr. Abc Xyzmpat.
Examination : M.R.I. of the Dorsal Spine.
CLINICAL PROFILE :
Known C/O Kochs spine, detected on 00.00.00. On AKT since then.
C/O weakness of BLE with incontinence of urine since 1 month.
M.R.I of the 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.
After administration of contrast, 4 mm thick T1 Weighted sagittal images and 5 mm thick T1 Weighted axial images were obtained through the dorsal region.
The lumbar spine was scanned with 4 mm thick T1 Weighted and T2 Weighted sagittal images and 6 mm thick T1 Weighted axial images after contrast administration. The cervico-dorsal region was also screened with 4 mm thick T1 Weighted sagittal images after contrast administration.
There is loss of water content of the dorsal intervertebral discs. Small posterior peridiscal osteophytes are noted at the D7-D8, D8-D9, D9-D10, D10-D11 and D11-D12 levels.
A hemangioma with fat content (hyperintense on all the pulse sequences) is noted at the D11 vertebral body.
The rest of the visualized dorsal vertebral bodies reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The visualized dorsal spinal cord appears slightly smaller in diameter without change is signal intensity. There is no cord compression. The dorsal spinal cord at the D4-D5, D6 and D7 levels shows an irregular margin.
The conus medullaris terminates at the L1 level.
After administration of contrast, there is no focal area of abnormal enhancement in the dorsal spinal cord or the meninges.
Images of the lumbar spine reveal an ill-defined hyperintense signal on the T2 Weighted images in the L2 and L3 vertebral bodies and the L2-L3 and L4-L5 intervertebral discs. Patchy enhancement is noted , after contrast administration in the L2 and L3 vertebral bodies. Patchy enhancement is also noted in the psoas muscles bilaterally. There is an intermediate signal intensity soft tissue lesion in the anterior epidural space extending over the L3 and L4 vertebral levels. This lesion enhances peripherally after contrast administration.
Posteriorly herniated discs with peridiscal osteophytes are noted at the L1-L2, L2-L3, L3-L4, L4-L5 and L5-S1 levels. Bilateral neural foraminal narrowing is also noted at these levels. Facetal hypertrophy is noted at the L4-L5 and L5-S1 levels with ligamentum flavum hypertrophy at the L5-S1 and S1 levels and a resultant tight lumbar spinal canal at these levels.
No abnormality is detected in the visualized cervico-dorsal region on this study..
1. Slight decrease in calibre of the dorsal spinal cord without change in signal intensity with irregular cord margin as described may be the sequelae of previous arachnoiditis.
2. Altered signal in the L2 and L3 vertebral bodies and the L2-L3 and L4-L5 intervertebral discs with patchy enhancement after contrast administration, as described most likely is due to osteitis with discitis, probably tuberculous in etiology.
- 3 - Scan-00008
3. Patchy enhancement in the psoas muscles bilaterally may be infective/inflammatory in etiology.
4. Soft tissue lesion in the anterior epidural space extending over L3 and L4 vertebral levels as described may represent granulation tissue/abscess.
5. Posteriorly herniated discs with peridiscal osteophytes at the L1-L2, L2-L3, L3-L4, L4-L5 and L5-S1 levels.
6. Facetal hypertrophy at the L4-L5 and L5-S1 levels with ligamentum flavum hypertrophy at the L5-S1 and S1 levels and a resultant tight lumbar spinal canal at these levels.
As compared to the previous MRI dated 00.00.00, there is slight decrease in the soft tissue in the anterior epidural space over the L3 and L4 vertebral levels and the posterior epidural space lesion at the D10/D11 level is not appear on this study.