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Date : 00.00.00

Name of the Patient : Abc Xyza lmn / F / 33 yrs.
Referred by : Dr. Abc Xyzchale.
Examination : M.R.I. of the Dorsal Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE.

EXAMINATION :

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.

OBSERVATION :

The D4 and D5 vertebral bodies appear hypointense on the T1 Weighted images and turn hyperintense on the T2 Weighted images. The D4-D5 intervertebral disc is reduced in height and also appears hyperintense on the T2 Weighted images, with breach of the adjacent cortical endplates.

There is seen an intermediate signal intensity soft tissue lesion on the T1 Weighted images in the prevertebral and right paravertebral region, extending over the D4 and D5 vertebral levels. This lesion also appears hyperintense on the T2 Weighted images. There is extension into the anterior epidural space on the right with resultant mild cord compression at the D4 and D5 vertebral levels. The dorsal spinal cord however shows normal signal intensity. Soft tissue is also seen to extend into the right neural foramen at the D4-D5 level with encasement of the right D5 nerve root. Erosion of the right pedicle of the D4 and D5 vertebrae and the right lateral margin of the D4 body is noted. The D6 vertebral body shows an ill-defined, hypointense signal on all the pulse sequences, without obvious cortical break or bone erosion.


The rest of the visualized dorsal vertebral bodies (except D12) and intervertebral discs reveal normal signal intensity. The facet joints are unremarkable.

The visualized dorsal spinal cord reveals normal signal intensity.

Note is made of an enlarged right paratracheal lymph node.

The conus medullaris terminates at the L1 level.

Screening, T2 Weighted sagittal images of the cervical spine do not reveal any significant feature of note.

Screening, T1 Weighted sagittal images of the lumbar spine reveal ill-defined hypointense signal in the D12, L2, S1 and S2 vertebral bodies with probable involvement of the L5-S1 intervertebral disc.

IMPRESSION :

Altered signal in the D4 and D5 vertebral bodies and the D4-D5 intervertebral disc most likely represents osteitis with discitis, probably tuberculous in etiology. Prevertebral, right paravertebral and epidural soft tissue lesion would represent granulation tissue/abscess. There is mild cord compression at the D4 and D5 vertebral levels without change in cord signal intensity.

Probable involvement of the D12, L2, S1 and S2 vertebral bodies and the L5-S1 disc is also noted.

The possibility of the above described lesion representing a neoplasm is less likely.


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