sb/bv/rg/nl
Name of the Patient : Abc XyzGlmn / F / 36 yrs.
Referred by : Dr. Abc Xyzauhan.
Examination : M.R.I. of the Dorsal Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE (right more than left) since 1 year.
H/O Pulmonary Kochs 5 years ago. Received AKT.
Alleged H/O fall 4 years ago.
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.
The lumbar spine was screened with 5 mm thick T1 Weighted and T2 Weighted sagittal images and 5 mm thick T1 Weighted and T2 Weighted axial images.
OBSERVATION :
There is scoliosis of the upper dorsal spine with convexity to the left.
There is seen a CSF signal intensity lesion on all the pulse sequences in the dorsal spinal cord, centrally, extending over the D7 to D11 vertebral levels. This lesion most likely represents a syrinx. The visualized upper dorsal spinal cord appears slightly smaller in calibre without change in signal intensity.
The visualized dorsal vertebral bodies appear slightly more hypointense as compared to the normal on the T1 Weighted images.
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The visualized dorsal intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1 level.
Screening images of the lumbar spine reveal similar marrow signal change as in the dorsal region. Slight facetal hypertrophy is noted in the lumbar region. The L5 vertebral body is sacralized.
Screening T2 Weighted sagittal images of the cervico-dorsal region reveal degenerative changes in the mid-cervical region.
Incidentally noted is a soft tissue lesion at the apex of the right lung and probable fractures of the left seventh, eighth and ninth ribs posteriorly and right sixth, seventh and ninth ribs posteriorly. Also noted is mild splenomegaly and marrow changes in the visualized pelvic bone.
IMPRESSION :
1. Scoliosis of the upper dorsal spine with convexity to the left.
2. A CSF signal intensity lesion on all the pulse sequences in the dorsal spinal cord, centrally, extending over the D7 to D11 vertebral levels
most likely represents a syrinx. The visualized upper dorsal spinal cord appears slightly smaller in calibre without change in signal intensity.
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3. Altered signal in the visualized vertebral bodies and the pelvic bones as described is not specific for a single etiology. These changes may either represent preponderance of hematopoietic marrow or may suggest a hematopoietic disorder.
4. Slight facetal hypertrophy in the lumbar region.
5. Multiple ribs fractures, posteriorly as described.
6. Soft tissue lesion in the apex of the right lung may be due to previous pulmonary tuberculosis.