Date : 00.00.00

Name of the Patient : Abc Xyzoylmn / M / 30 yrs.
Referred by : Dr. Abc Xyzs.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

H/O accidental injury in October 0000 with quadriplegia. Treated with traction and improved partially.
C/O weakness of grip on the right side, walks with crutches, low back pain, gait imbalance, more to the left and buckling of knees since then.

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 slight loss of water content of the cervical intervertebral discs.

A small postero-central protruded disc with peridiscal osteophytes is noted at the C2-C3 level.

A small postero-central and right postero-lateral disc herniation with peridiscal osteophytes is noted at the C3-C4 level with right neural foraminal narrowing.

Small posterior peridiscal osteophytes are noted at the C4-C5 and C5-C6 levels.
Scan : 00000


There is a focal hypointense signal on the T1 Weighted images in the cervical spinal cord at the C3-C4 level. This lesion appears hyperintense on the T2 Weighted and Fast Scan (T2 *) images and represents an area of myelomalacia ? the sequelae of previous cord contusion (past H/O cervical injury).

The cervical vertebral bodies show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.

The atlanto-axial region and the cervico-medullary junction are unremarkable.

IMPRESSION :

1. A small postero-central protruded disc with peridiscal osteophytes at the C2-C3 level.

2. A small postero-central and right postero-lateral disc herniation with peridiscal osteophytes at the C3-C4 level.

3. Altered signal in the cervical spinal cord at the C3-C4 level which may represent an area of myelomalacia ? the sequelae of previous cord contusion (past H/O cervical injury).