sb/ke/nl/nl
Date : 00.00.00
Name of the Patient : Abc Xyzudlmn / F / 40 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Dorsal Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE.
C/O weakness of BLE since 2 1/2 years.
H/O fall prior to this.
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 evidence of facetal hypertrophy at the D9-D10 level bilaterally with resultant cord compression. The dorsal spinal cord at this level shows a hyperintense signal on the T2 Weighted images which suggest cord edema/ischemia/gliosis.
Facetal hypertrophy, but to a lesser extent is also noted at the D11-D12 level and the D4-D5 levels with mild compromise of the dorsal canal at these levels.
The visualized dorsal vertebral bodies show normal signal intensity. The intervertebral discs show loss of water content. The visualized pre and paravertebral soft tissues are unremarkable.
Screening, T2 Weighted sagittal images of the cervical cord shows a posterior peridiscal osteophyte at the C5-C6 level and smaller, postero-central protruded discs with peridiscal osteophytes at the C3-C4, C4-C5 and C6-C7 levels.
IMPRESSION :
1. Facetal hypertrophy at the D9-D10 level bilaterally with resultant cord compression and cord signal alteration suggesting cord edema/ischemia/gliosis.
2. Facetal hypertrophy, but to a lesser extent at the D11-D12 level and the D4-D5 levels with mild compromise of the dorsal canal at these levels.
3. A posterior peridiscal osteophyte at the C5-C6 level.