sb/ke
Date : 00.00.00

Name of the Patient : Abc Xyzen Plmn / F / 20 yrs.
Referred by : Dr. Abc XyzBhojraj.
Examination : M.R.I. of the Dorsal Spine.

CLINICAL PROFILE :

H/O anterior spinal decompression with internal gibbectomy at the D6-D7 level on 00.00.00.
C/O weakness of the LLE since 1 year.

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 probable segmentation anomalies of the D4, D5 and D6 vertebrae with an angular kyphus at these levels. There is evidence of surgical intervention at these levels with partial excision of the vertebral bodies and probably the pedicles on the left, at these levels.

There is an intermediate signal intensity lesion on the T1 Weighted images in the anterior epidural space over the D4 to D6 vertebral levels which appears hyperintense on the T2 Weighted images. These changes are most likely post-operative in etiology and this lesion may represent surgical hemostatic material/fibrous tissue.

The dorsal spinal cord over the D4 to D6 vertebral levels appears smaller in calibre and shows a hyperintense signal on the T2 Weighted images which may represent cord ischemia/gliosis.




The rest of the visualized dorsal vertebral bodies and intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12 level.

IMPRESSION :

1. Post-operative status.

2. Probable segmentation anomalies at the D4, D5 and D6 vertebrae with a kyphus at these levels.

3. Soft tissue lesion in the anterior epidural space over the D4 to D6 vertebral levels may represent surgical hemostatic material/fibrous tissue.

4. Decreased calibre of the dorsal spinal cord over the D4 to D6 vertebral levels with altered signal may suggest cord ischemia/gliosis.

As compared to the previous MRI dated 00.00.00, the patient is now status post-operative with excision of gibbus in the mid dorsal region. There is however, no significant change in the calibre of the dorsal spinal cord at that level.