sb/ke/nl/nl







Name of the Patient : Abc XyzM. Salulmn / M / 45 yrs.
Referred by : Dr. Abc Xyzauhan.
Examination : M.R.I. of the Dorsal Spine.

CLINICAL PROFILE :

Alleged H/O fall with paraplegia and bladder/bowel involvement 4 years ago for which thoracotomy with cord decompression was done.
But complaints still persists.

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 :

There is slight loss of water content of the dorsal intervertebral discs.

There is evidence of surgical intervention with probable bone grafting at the D11/D12 level on the left. The D11 vertebral body in its left half shows a heterogeneously signal on all the pulse sequences. The D10-D11 and D11-D12 intervertebral discs are not well-defined. Decrease in height of the D11 and D12 vertebral bodies is noted with a kyphus at the dorso-lumbar junction.

Posterior peridiscal osteophytes are noted at the D10-D11 and D11-D12 levels indenting the anterior dural theca at the D10-D11 level.


A postero-central disc herniation with peridiscal osteophytes is noted at the D12-L1 level. Slight inferior migration of the disc is seen.

The spinal cord from about the D9 vertebral level upto the tip of the conus medullaris appears atrophied, shows an irregular margin and a hyperintense signal on the T2 Weighted images which suggest myelomalacic changes. The dorsal spinal cord at the D10 and D11 levels appears as a very thin strand and is nearly not visualized.

The rest of the visualized upper and mid dorsal spinal cord also appears atrophied.

Slight facetal hypertrophy is noted in the lower dorsal region.

There is slight central wedging of the D8 vertebral body which may also be the sequelae of previous trauma.

The rest of the visualized dorsal vertebral bodies show spotty fatty marrow changes. The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1-L2 level.

Incidental note is made of mild bilateral hydronephrosis which may be further evaluated.

Screening, T2 Weighted sagittal images of the cervical spine reveal small postero-central protruded discs with peridiscal osteophytes at the C3-C4, C4-C5 and C5-C6 levels.

Screening, images of the lumbar spine do not reveal any significant feature of note.
..3/.











- 3 - Scan-00002


IMPRESSION :

1. Post-operative status with changes in the D11 and D12 vertebral bodies which may be sequelae of previous trauma and subsequent surgery.

2. Posterior peridiscal osteophytes at the D10-D11 and D11-D12 levels.

3. A postero-central disc herniation with peridiscal osteophytes at the D12-L1 level.

4. Spinal cord from about the D9 vertebral level upto the tip of the conus medullaris appears atrophied, shows an irregular margin with altered signal suggesting myelomalacic changes. The dorsal spinal cord at the D10 and D11 levels appears as a very thin strand and is nearly not visualized.

5. Slight facetal hypertrophy in the lower dorsal region.

6. Mild bilateral hydronephrosis may be further evaluated.