ke/sb/rg.
Date : 00.00.00
Name of the Patient : Abc Xyz Shlmn / F / 25 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Dorsal Spine.
CLINICAL PROFILE :
Known C/O kochs spine.
H/O laminectomy over the D8 to L1 levels with removal of intramedullary SOL on 00.00.00 and 00.00.00.
C/O backache radiating to the LLE with weakness of BLE since 2 months.
Received 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.
8 mm thick T1 Weighted and T2 Weighted axial images.
OBSERVATION :
There are post-operative changes in the dorso-lumbar region over D9 to L1 levels.
The dorsal spinal cord over the D10 and D11 levels appears atrophied. Hypointense areas are noted within the spinal cord over these levels which turn hyperintense on the T2 Weighted images and would represent gliosis/myelomalacia. No obvious mass lesion is seen in the lower dorsal spinal cord.
The dorsal vertebral bodies and the intervertebral discs reveal normal signal intensity.
The conus medullaries terminates at the L1 level.
The cervico-dorsal spine was screened with 4 mm thick T2 Weighted sagittal images. Suspicious intramedullary granuloma is still noted in the cervical cord at the C7 level.
..2/.
IMPRESSION :
In a known C/O Kochs spine the MRI features are suggestive of :1. Post-operative status.
2. Cord atrophy over the D10 and D11 levels with cord signal alteration over these levels suggestive of gliosis/myelomalacia.
As compared to the previous MRI (scan no.0000) dated 00.00.00 there is no significant change noted.