Date : 00.00.00
Name of the Patient : Abc XyzSubhanlmn / M / 60 yrs.
Referred by : Dr. Abc Xyzlwalkar.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neck pain with numbness in BUE and BLE and gait imbalance since 2 months.
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
3 mm T1 Weighted coronal images.
5 mm thick T1 Weighted sagittal images in flexion and extension.
There is reduction in height and loss of water content of the cervical intervertebral discs.
Posterior disc bulges with posterior peridiscal osteophytes are noted at the C2-C3, C3-C4, C4-C5, C5-C6 and C6-C7 levels. Indentation on the cervical spinal cord is noted at the C3-C4, C4-C5 and C5-C6 levels. There is also ligamentum flavum hypertrophy at these levels with resultant tight lumbar canal at these levels.
There is atrophy of the cervical spinal cord at the C1-C2 level. The cervical spinal cord at this level shows a hyperintense signal on the T2 Weighted images posteriorly (isointense to normal cord on the T1 Weighted images) suggesting cord ischemia/contusion/gliosis. The atlanto-dens interval measures approximately 1.0 mm in the neutral position and approximately 8.0 mm in flexion. It reverts back to normal position in extension suggesting a mobile atlanto-axial dislocation.
The upper cervical vertebral bodies show spotty fatty marrow changes. The joints of Luschka at the C5-C6 level on the left shows degenerative changes. The facet joints at the C3-C4, C4-C5 and C5-C6 levels also appear slightly hypertrophied.
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The visualized pre and paravertebral soft tissues are unremarkable.
1. Mobile atlanto-dens subluxation with the atlanto-dens interval measuring approximately 8.0 mms in flexion and 1.0 mm in the neutral and extended positions.
2. Atrophy of the cervical spinal cord at the C1-C2 level with altered signal posteriorly as described may represent cord ischemia/contusion/gliosis in the given clinical setting.
3. Posterior disc bulges with posterior peridiscal osteophytes at the C2-C3, C3-C4, C4-C5, C5-C6 and C6-C7 levels with ligamentum flavum hypertrophy at the C3-C4, C4- C5 and C5-C6 levels with a tight cervical canal at these levels.