Medical Imaging Analysis Report

1. Imaging Findings

In the longitudinal or transverse images of the thoracic spine, a distinct sagittal cleft can be observed in one vertebra, with the left and right sides appearing to separate from the center, presenting a “butterfly-shaped” appearance. The margin of the vertebra is smooth, with no newly observed bony destruction or significant sclerosis. The intervertebral disc and the adjacent vertebrae above and below show corresponding slight concavity of the endplates in response to load bearing, and there is no obvious pathological lesion or fracture noted.

2. Potential Diagnoses

1. Congenital Butterfly Vertebra (Sagittal Cleft Vertebra)
   Based on the typical morphological changes of this vertebra and the smooth lesion margin, this finding aligns with a congenital developmental anomaly.
2. Vertebral Fracture or Pathologic Destruction
   Although imaging shows a sagittal cleft, if there is a history of significant trauma or malignancy, a fracture or pathological destruction must be ruled out. However, there is no clear sign of bony destruction, so the likelihood is low.
3. Local Infection
   Infection can lead to vertebral destruction or abnormal signal changes, but imaging does not indicate soft tissue swelling or vertebral destruction, making this possibility relatively low.

3. Final Diagnosis

Based on the currently available patient history and imaging findings, this vertebral deformity is consistent with the characteristic imaging features of a “congenital butterfly vertebra.” Such anomalies are often incidental findings, and most patients have no significant symptoms or require special treatment. If no other pathologies are detected, it can be regarded as a congenital variation.

4. Treatment Plan and Rehabilitation Program

For a simple congenital butterfly vertebra in an asymptomatic patient, no specific treatment is generally required. The main points of attention include:

1. Routine Follow-up and Observation
   Undergo periodic imaging examinations to monitor for new symptoms such as spinal pain, progression of deformity, or neurological signs. If any abnormalities are noted, further evaluation is warranted.
2. Conservative Rehabilitation Training
   In the absence of significant spinal deformity or neurological symptoms, basic spinal stability exercises (such as core muscle training) can be performed to maintain proper spinal alignment and reduce the risk of subsequent degenerative changes.
3. Exercise Prescription Recommendations (FITT-VP Principle)
   • Frequency (F): 2-3 times per week of core and posture control training.
   • Intensity (I): Light to moderate intensity, avoiding sudden heavy spinal loading or high-impact activities.
   • Time (T): Approximately 10-20 minutes per session, which can be gradually increased based on individual tolerance.
   • Type (T): Emphasize gentle core strength training, stretching exercises, and low-impact aerobic activities (e.g., swimming, stationary cycling).
   • Progression (P): Increase the duration or frequency gradually as fitness improves, while closely monitoring for any back discomfort or adverse reactions.
4. Surgery or Other Interventions
   If there are other spinal structural abnormalities, spinal cord compression, or neurological deficits, further surgical evaluation may be required. However, in an isolated, asymptomatic butterfly vertebra, surgery is generally not indicated.

Throughout the rehabilitation program, close attention should be paid to signs of back pain or progression of spinal deformity. Adjust exercise volume individually according to the patient’s condition (e.g., bone density, cardiopulmonary endurance) to ensure safe and effective training.

Disclaimer: This report is based on the limited information provided by the patient and is intended as a reference analysis. It does not replace in-person consultation or professional medical advice. For specific treatment plans, please refer to the patient’s actual clinical condition and consult professional medical institutions.