sb/hs/rg/nl
Date : 00.00.00
Name of the Patient : Abc XyzMohd. Ludhlmn / F / 19 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neck pain radiating to the RUE with weakness since 2 months.
H/O fever.
EXAMINATION :
M.R.I of the cervical spine was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and Fast Scan (T2 *) axial images.
OBSERVATION :
There is loss of normal cervical lordosis.
The C5, C6 and C7 vertebral bodies appear hypointense on the T1 Weighted images and hyperintense on the T2 Weighted images. Involvement of the left sided pedicles, left laminae, and transverse process of the C5 and C6 vertebrae is noted. The left C7 pedicle is also involved. The C5-C6 and C6-C7 intervertebral discs are also involved.
There is seen an intermediate signal intensity lesion on the T1 Weighted images in the left paravertebral region, left posterior paraspinal region and in the anterior epidural space over the C5 to C7 vertebral levels. This lesion appears hyperintense on the T2 Weighted images. Resultant slight lateral displacement of the left vertebral artery over these levels is noted. There is also mild cord compression over the C5 to C7 vertebral levels. The cord shows a slight increase in signal intensity.
- 2 - Scan-00003
The rest of the cervical vertebral bodies and the remaining intervertebral discs show normal signal intensity. The joints of Luschka are unremarkable.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
IMPRESSION :
Altered signal of the C5, C6 and C7 vertebrae and C5-C6 and C6-C7 intervertebral discs most likely represents osteitis with discitis probably tuberculous in etiology. Left paravertebral, left paraspinal and anterior epidural soft tissue lesion over the C5 to C7 vertebral levels may represent granulation tissue/abscess. There is mild cord compression with cord edema/ischemia/myelitis.
The possibility of this lesion representing a neoplasm like a round cell tumor seems less likely.