ke/sb
Date : 00.00.00

Name of the Patient : Abc XyzYlmn / M / 33 yrs.
Referred by : Dr. Abc Xyzah / Dr. Abc Xyzolkar.
Examination : M.R.I. of the Dorsal Spine.

CLINICAL PROFILE :

C/O backache in November 0000 for which laminectomy for L4-L5 PID was done 4 months back. Since then C/O numbness in BLE.

EXAMINATION :

M.R.I of the dorsal spine was performed using the following parameters :

5 mm thick T1 Weighted and T2 Weighted sagittal images.

5 mm thick T1 Weighted, T2 Weighted and Fast Scan (T2 *) axial images.

OBSERVATION :

There is hypertrophy of the facet joints at the D2-D3 level with a bony spur/calcified ligament and compression and anterior displacement of the spinal cord at this level. The cord shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images at this level (isointense to normal cord on the T1 Weighted images) suggesting cord edema/ischemia.

A left postero-lateral disc herniation is seen at the D6-D7 level with antero-lateral compression of the spinal cord. A large peridiscal osteophyte is noted at this level. The spinal cord at this level shows a hyperintense signal on the T2 Weighted images (isointense to normal cord on the T1 Weighted images) suggestive of cord edema/ischemia. Facetal and ligamentous hypertrophy/calcification is noted at this level.

Fairly large, left and right postero-lateral disc herniations are noted at the D5-D6 level.

There are right paracentral disc herniations at the D7-D8 and D8-D9 levels with antero-lateral compression of the cord.

The D5-D6, D6-D7, D7-D8 and the D11-D12 intervertebral discs show loss of water content.

Facetal hypertrophy is also noted at the D3-D4 and the D4-D5 levels.

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

The cervico-dorsal spine was screened with 5 mm thick T2 Weighted sagittal images which shows small posterior disc bulges at the C4-C5 and C5-C6 levels.

The lumbar spine was screened with 5 mm thick T1 Weighted sagittal images and 5 mm thick T2 Weighted axial images which shows post-operative changes at the L4 and L5 levels with apparent posterior disc herniations with peridiscal osteophytes at the L4-L5 and L5-S1 levels. The intrathecal nerve roots are unremarkable.

IMPRESSION :

1. Hypertrophy of the facet joints with a bony spur/calcified ligament at the D2-D3 level with compression and anterior displacement of the spinal cord at this level. Cord signal alteration at this level suggests cord edema/ischemia.
..3/.












- 3 - Scan-00002


2. A left postero-lateral disc herniation at the D6-D7 level with a large peridiscal osteophyte at this level. Cord signal alteration at the D6-D7 level suggests cord edema/ischemia.

3. Right paracentral disc herniations at the D7-D8 and D8-D9 levels.

4. Facetal hypertrophy at the D3-D4 and the D4-D5 levels.

5. Small posterior disc bulges at the C4-C5 and C5-C6 levels.

6. Apparent posterior disc herniations with peridiscal osteophytes at the L4-L5 and L5-S1 levels with post-operative changes at these levels.

7. Left and right postero-lateral disc herniations at the D5-D6 levels.