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sb/hs/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz P. lmn / M / 17 yrs.
Referred by : Dr. Abc Xyzngoi.
Examination : M.R.I. of the Cervico-dorsal Spine.

CLINICAL PROFILE :

Past H/O laminectomy in the upper dorsal region with excision of an intramedullary tumor 3 years ago (for weakness in the LLE). Repeat surgery with excision of tumor done on 00.00.00.
Histopathology s/o intramedullary astrocytoma.

EXAMINATION :

M.R.I of the cervico-dorsal spine was performed using the following parameters :

4 mm thick T1 Weighted and T2 Weighted sagittal images.

8 mm thick T1 Weighted and T2 Weighted axial images.

After administration of contrast, 4 mm thick T1 Weighted sagittal images and 8 mm thick T1 Weighted axial images (with fat saturation) were obtained.

The cervical and dorso-lumbar spines were screened with 4 mm thick T1 Weighted (with fat saturation) sagittal images.

OBSERVATION :

There is evidence of laminectomy over the D4 to D6 vertebral levels with post-operative changes in the soft tissues in the posterior dorsal region over these levels.

The visualized cervico-dorsal spinal cord appears slightly larger in diameter as compared to the normal. There is an intermediate signal intensity mass lesion on the T1 Weighted images in the cervico-dorsal region which appears hyperintense on the T2 Weighted images. This lesion is not well-delineated from the normal cord on the unenhanced scan. After contrast administration, there is intense enhancement of the mass lesion in the cervico-dorsal region which is seen to extend over the
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C5-C6 to the D7 vertebral levels. This lesion is seen to be placed, centrally and posteriorly within the spinal cord. The cervical and dorsal spinal cords proximal and distal to the enhancing lesion shows evidence of a syrinx. The syrinx is seen to extend upto the conus medullaris, inferiorly and upto the C3 vertebral level, superiorly. The D5 and D6 vertebral bodies appear slightly wedged anteriorly without change in signal intensity.

The visualized cervico-dorsal vertebral bodies and intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12-L1 level.

IMPRESSION :

1. Post-operative status.

2. An intensely enhancing intramedullary mass lesion within the cervico-dorsal spinal cord over the C5-C6 to the D7 vertebral levels as described, most likely represents a residual/recurrent intramedullary astrocytoma.

As compared to the previous MRI dated 00.00.00, there is no significant change.
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