Species:CanineAge:12 years 10 monthsModality/Images:CT/1336 Wt: N/ATemp: N/APatient ID:3127364Breed:CrossbreedSex:MDate Of Study:Wed, 27 Sep 2023Pulse: N/AResp: N/A
Pertinent Case Information*
Politrauma after falling from the balcony.On neurologic examination there is a right thoracic monoparesis with absent withdrawal reflex and absent deep sensation on the medial part of the limb.On arrival he disclosed pneumothorax and drainage was necessary.
Differential Diagnosis*
– Partial plexus avulsion.- Fracture.
Findings:
EXAMINATION: Whole-body CT Followed by positive contrast myelography are available for interpretation (since 4 sequences; 1336 images).HEAD AND NECK:– In the rostral left and right mandibles there are questionably minimally displaced fractures surrounding the roots of the canine teeth.– The rest of the bony structures of the head are normal.– The intracranial structures are normal.– The nasal cavities and tympanic cavities are normal.– The C5 – 6 intervertebral disc space is severely narrowed with increased vertebral endplate sclerosis and mild ventral subluxation of C6 in relation to C5 vertebral bodies.– The right transverse process of C7 vertebra is fractured and mildly displaced surrounded by mild soft tissue swelling.– Although the positive contrast within the subarachnoid space extends to the cranial thoracic vertebral canal, Compressive myelopathy is not identified in the neck.THORAX:– Both pleural cavities contain a small amount of free gas.– Within the ventral aspect of the right middle lung lobe there is a focal increase in soft tissue attenuation.– Within the right caudodorsal lung field there is a small size, round gas-filled structure consistent with bulla.– The cranial mediastinal structures including the lymph nodes are normal.– No additional fractures are identified.ABDOMEN:– The stomach and intestine are normal.– The liver, spleen, kidneys, urinary bladder, generalized, and pancreas are normal.– The lymph nodes of the abdomen are normal.
Assessment:
SUMMARY:1. Acute traumatic fractures, right transverse processes, C7 – T12. Intervertebral disc collapse with subluxation, C5 – 63. Questionable, bilateral, rostral mandibular fractures4. Mild bilateral pneumothorax5. Small, focal pulmonary bulla, right caudodorsal lung field6. Small, focal pulmonary attenuation, right middle lung lobeThe patient’s clinical signs are attributed the changes associated with the caudal neck. The collapsing of the intervertebral disc space along with subluxation causes regional inflammation that can affect the lateral nerve root. The fractures within the transverse processes of the C7 and T1 vertebrae result in locally extensive softtissue swelling which likely also creates neuropathy involving the nerve roots. the focal attenuation within the right middle lung lobe is likely secondary to pulmonary contusion from the trauma.Specialist:Dr. Assaf Lerer, DACVRFor the next few days, I am available:Phone:(251) 207-4764Wed Sep 27 12:00 PM – 11:00 PM CESTEmail:Assaf.Lerer@antechimagingservices.comThu Sep 28 12:00 PM – 11:00 PM CESTDate of Report:Wed, 27 Sep 2023 14:38:42 EDTTue Oct 3 12:00 PM – 11:00 PM CESTThank you for allowing us to be part of your diagnostic team; if you have any questions please contact me directly. Please note AIS will only discuss this report with the referring doctor.
Report Images
*questionable, minimally displaced fracture, rostral mandibles
*mild, subluxation with collapse disc space, C5 6
*acute traumatic fracture, transverse process, right C7
*acute traumatic fracture, right transverse process T1
*small size, focal bulla, right caudal lung lobe
*mild, left pneumothorax
*small, focal pulmonary attenuation, right middle lung lobe
