sb/ke/nl/rg.
Date : 00.00.00
Name of the Patient : Abc Xyz Mlmn / F / 20 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervico-dorsal Spine.
CLINICAL PROFILE :
C/O backache since 7-8 months.
H/O ? Kochs spine. Not completed AKT.
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 :
The D7 vertebral body is as marked on the film.
There is near complete collapse of the D5 vertebral body and partial collapse of the D4 vertebral body. The D4-D5 intervertebral disc is not well-identified. The visualized D4 and D5 vertebral bodies appear hypointense on the T1 Weighted images and hyperintense on the T2 Weighted images. The D3-D4 and D5-D6 intervertebral discs appear intact. There is minimal prevertebral and paravertebral soft tissue lesion at the D4 and D5 vertebral levels which also appears hyperintense on the T2 Weighted images. Minimal extension of the soft tissue lesion in the anterior epidural space is noted. The D2 vertebral body also appears hypointense on the T1 Weighted images and hyperintense on the T2 Weighted images.
The rest of the visualized cervico-dorsal vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints are unremarkable.
The visualized cervico-dorsal spinal cord reveals normal signal intensity. There is no cord compression.
..2/.
T1 Weighted sagittal images of the dorso-lumbar spine do not reveal any significant feature of note.
IMPRESSION :
Complete collapse of the D4 and D5 vertebrae with altered signal as described most likely represents osteitis with discitis (D4-D5 disc), probably tuberculous in etiology. The prevertebral, paravertebral and anterior epidural soft tissue lesion would represent granulation tissue.
The possibility of a neoplasm seems less likely.