sb/bv
Date : 00.00.00
Name of the Patient : Abc Xyzla Suryavlmn / F / 30 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE:
C/O neck pain with swelling over the right and left shoulder since 2 months.
H/O abdominal kochs 2 years back for which patient received AKT.
EXAMINATION :
M.R.I of the cervical spine was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and Fast Scan (T2 *) axial images.
3 mm thick Fast scan (T2 *) and 5 mm thick T1 Weighted coronal images.
OBSERVATION :
There is an ill-defined hypointense signal on the T1 Weighted images involving the C2 vertebral body and the odontoid process. This lesion appears hyperintense on the T2 Weighted and Fast Scan (T2 *) images. Erosion of the anterior margin of body of C2, to the right of the midline is noted with minimal prevertebral soft tissue extension of the lesion at that level. There is no atlanto-dens subluxation.
A small, right paracentral protruded disc is noted at the C6-C7 level.
Small left paracentral protruded disc is noted at the C5-C6 level.
..2/.
There is a 5.0 mm diameter sized focal, hypointense signal on all pulse sequences in the postero-superior margin of the C7 vertebral body to the right of the midline. This most likely represents an osteoma/bone island.
The C4-C5 and C5-C6 intervertebral discs show slight loss of water content.
The rest of the cervical vertebral bodies show normal signal intensity. The joints of Luschka are unremarkable.
The cervical spinal cord shows normal signal intensity.
The cervico-medullary junction is unremarkable.
Small subcentimeter lymphnodes are noted deep to the sternoclidomastoid muscles bilaterally.
IMPRESSION :
Altered signal in the C2 vertebral body and the odontoid process most likely represents osteitis, probably tuberculous osteitis (in the given past H/O abdominal kochs). Minimal prevertebral soft tissue extension is noted to right of the midline.