sb/ke/rg/nl
Date : 00.00.00

Name of the Patient : Abc XyzDlmn / F / 65 yrs.
Referred by : Dr. Abc Xyzre.
Examination : M.R.I. of the Dorsal Spine.

CLINICAL PROFILE :

H/O transthoracic excision of Kochs granulation tissue at D5 with bone and disc material grafting.
C/O backache since 2 months.
H/O fall in March 0000.

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 past h/o transthoracic excision of tuberculous granulation tissue at D5 vertebral level with bone and disc material grafting. The D5 vertebral body is not well-identified, probably the sequelae of previous infection/surgery. A kyphus is noted at the D4/D5/D6 levels.

Subtle hypointense singal on all pulse sequences is noted along the inferior margin of the D4 vertebra. The intervening disc/bone graft between D4 and D6 vertebrae appears hypointense on all the pulse sequences and is seen to minimally indent the dural theca anteriorly. Bilateral neural foraminal narrowing is also noted at this level.

A Schmorls node/herniated disc is seen along the superior margin of the D6 vertebral body.

Subtle hyperintense signal on the T2 Weighted images is noted in the dorsal spinal cord at the D5 and D6 vertebral levels which may suggest cord ischemia/gliosis.
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There is anterior wedging of the D12 vertebral body with fatty marrow changes. Indentation on the anterior dural theca at this level is noted by the postero-superior margin of the D12 vertebral body.

The rest of the visualized dorsal vertebral bodies show spotty fatty marrow changes. The dorsal intervertebral discs show loss of water content. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12-L1 level.

IMPRESSION :

1. Post-operative status with non-visualization of the D5 vertebral body with bone/disc graft at that level.

2. Subtle altered signal in the dorsal spinal cord at the D5 and D6 vertebral levels may suggests cord ischemia/gliosis.

3. Anterior wedging of the D12 vertebral body with fatty marrow changes is ? the sequelae of previous trauma/infection.

As compared to the previous MRI dated 00.00.00 (scan no.0000), there is near complete resolution of the previous identified osteitis and granulation tissue.