sb/ke/nl/nl
Date : 00.00.00
Name of the Patient : Abc Xyzh Bolmn / M / 62 yrs.
Referred by : Dr. Abc Xyznghal.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neckpain radiating to the RUE with paresthesias in the RUE and RLE since 4-5 months.
EXAMINATION :
M.R.I of the cervical spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
4 mm thick T1 Weighted and Fast Scan (T2 *) axial images.
4 mm thick T1 Weighted coronal images.
OBSERVATION :
There is loss of water content of the cervical intervertebral discs.
A congenital block C5/C6 vertebra is noted.
The atlanto-dens interval measures approximately 3.0 mms. Irregularity of the articular margin of the anterior arch of C1 and the odontoid process is noted with a hypointense signal on all the pulse sequences in the C1-C2 joint space which may represent fibrous tissue. There is however, no cord compression noted at the C1-C2 level.
Small posterior disc bulges with fairly large, posterior peridiscal osteophytes are noted at the C2-C3, C3-C4 and C4-C5 levels, indenting the cervical spinal cord anteriorly. The cervical spinal cord at the C4 and C6 vertebral levels shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images, which appears hypointense on the T1 Weighted images and may represent myelomalacic changes. Hyperintense signal is also noted in the cord at the C2 and C3 levels on the T2 Weighted and Fast Scan (T2 *) images suggestive of cord edema/ischemia.
Small posterior disc bulge is noted at the C6-C7 level.
Far lateral peridiscal osteophytes are noted at the C3-C4, C4-C5 and C5-C6 levels.
Ligamentum flavum hypertrophy is noted at the C3-C4 and C4-C5 levels. Hypertrophic facetal arthropathy is noted at the C3-C4, C4-C5, C5-C6 and C6-C7 levels bilaterally. Degenerative changes of the joints of Luschka is noted at the C2-C3 level on the right and at the C3-C4 and C6-C7 levels bilaterally with slight neural foraminal narrowing.
The cervical vertebral bodies show normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The cervico-medullary junction is unremarkable.
IMPRESSION :
1. Changes described at the C1-C2 level most likely represent degenerative changes.
2. Small posterior disc bulges with fairly large, posterior peridiscal osteophytes at the C2-C3, C3-C4 and C4-C5 levels.
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3. Cord edema/ischemia at the C2 and C3 vertebral levels.
4. Altered cord signal at the C4 and C6 vertebral levels may represent myelomalacic changes.
5. Small posterior disc bulge at the C6-C7 level.
6. Far lateral peridiscal osteophytes at the C3-C4, C4-C5 and C5-C6 levels.
7. Ligamentum flavum hypertrophy at the C3-C4 and C4-C5 levels.
8. Hypertrophic facetal arthropathy at the C3-C4, C4-C5, C5-C6 and C6-C7 levels bilaterally with degenerative changes of the joints of Luschka at the C2-C3 level on the right and at the C3-C4 and C6-C7 levels bilaterally.
9. Canal stenosis at the C3-C4 and C4-C5 levels.