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Date : 00.00.00
sb/bv
Name of the Patient : Abc Xyzakant M. lmn / M / 42 yrs.
Referred by : Dr. Abc Xyzshtekar.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O neck pain, radiating to BUE with paresthesias since 7-8 years.

EXAMINATION :

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

5 mm thick T1 Weighted and T2 Weighted sagittal images.

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

OBSERVATION :

There is scoliosis of the cervical spine with convexity to the left. There is loss of water content of the cervical intervertebral discs . Clockwise rotation anomaly of upper cervical vertebrae is noted.

There is occipitalization of the atlas. The atlanto-dens interval measures approximately 2.3 mms.

Posterior disc bulges with posterior peridiscal osteophytes are noted at the C3-C4, C4-C5 and C5-C6 levels with indentation of the cervical spinal cord at the C3-C4 and C4-C5 levels. Slight neural foraminal narrowing is noted at these levels, bilaterally. There is also degenerative changes of the joints of Luschka at these levels. The cervical spinal canal appears tight at the C3-C4 level, with the spinal cord appearing triangular in shape.

The cervical spinal cord at the C3-C4 level shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images suggesting cord edema/ischemia.

The upper cervical vertebral bodies show spotty fatty marrow changes. The pre and paravertebral soft tissues are unremarkable.

The cervico-medullary junction is unremarkable.



- 2 -


IMPRESSION :

1. Occipitalization of the atlas.

2. Posterior disc bulges with posterior peridiscal osteophytes at the C3-C4, C4-C5 and C5-C6 levels with cord compression at the C3-C4 and C4-C5 levels and tight cervical canal at the C3-C4 level.

3. Altered signal of the cervical spinal cord at the C3-C4 level suggests cord edema/ischemia.

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    • Interventional Pain Procedure Templates
    • The Ultimate Guide to Rapid Reporting for FRCR 2B
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