sb/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz Kilmn / M / 21 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Dorsal Spine.

CLINICAL PROFILE :

H/O surgery at D4 for neurofibroma in 0000.
C/O right pleural effusion. On 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 :

There is evidence of laminectomy over the D2 to D4 vertebral levels with post-operative changes in the soft tissues in the dorsal region over these levels. Probable excision of the right pedicle and transverse process of D3 vertebra is also noted. A CSF signal intensity lesion on all the pulse sequences in the right lateral epidural space at the D3 vertebral level would represent a pseudomeningocele, in the given clinical setting.

There is seen an intermediate signal intensity lesion on the T1 Weighted images in the right lateral epidural space at the D2-D3 level (scans 106.4, 105.6). This lesion appears slightly hyperintense on the T2 Weighted images.

The visualized dorsal vertebral bodies and intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
Scan-00003


The visualized dorsal spinal cord reveals normal signal intensity. There is no cord compression.

A fairly large loculated, right sided pleural effusion is noted.

IMPRESSION :

1. Post-operative status.

2. A CSF signal intensity lesion on all the pulse sequences in the right lateral epidural space at the D3 vertebral level would represent a pseudomeningocele, in the given clinical setting.

3. A small, altered signal intensity lesion in the right lateral epidural space at the D2-D3 level would represent a residual/recurrent nerve sheath tumor in the given clinical setting.

No previous investigations were available for comparison.