Date : 00.00.00
Name of the Patient : Abc Xyzyam Dhalmn / M / 45 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Dorsal Spine.
CLINICAL PROFILE :
C/O backache with paresthesias in BLE since 8-10 months which has increased since 1 month with bowel incontinence.
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.
Areas of hypointensity on the T1 Weighted images which turn hyperintense on the T2 Weighted images are seen to involve the D9 and D10 vertebral bodies and pedicles and the D9-D10 intervertebral disc with erosion of the adjacent cortical endplates.
There is slight extension of this pathologic process into the pre and paravertebral soft tissues and anterior epidural space over the D8-D9 to the D10-D11 levels. Also seen is extension into the D9-D10 neural foramina bilaterally with probable encasement of the corresponding nerve roots. There is involvement of the costo-vertebral and costo-transverse joints bilaterally at the D9 and D10 levels.
The rest of the visualized dorso-lumbar intervertebral discs show loss of water content.
The remaining visualized dorso-lumbar vertebral bodies reveal normal signal intensity.
The conus medullaris terminates at the D12 level.
Incidental note is made of a loculated pleural effusion on the left side.
The MRI features are suggestive of a pathologic process involving the D9 and D10 vertebrae and the D9-D10 intervertebral disc as described with a loculated left pleural effusion. This most likely represents an infective process like tuberculosis (less likely to represent a neoplastic process).