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Date : 00.00.00

Name of the Patient : Abc Xyzroman Tilmn / M / 65 yrs
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O paresthesias in all four limbs with difficulty in walking since 2 1/2 months and backache since 2 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 a large posterior disc extrusion at the C4-C5 level with anterior compression of the spinal cord. A large disc portion is seen to lie posterior to the C5 vertebral body. The spinal cord at the C4-C5 and C5 levels shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images (which is isointense to the normal cord on the T1 Weighted images) suggestive of cord edema/ischemia.

Small posterior disc herniations are noted at the C5-C6 and C6-C7 levels with anterior indentation of the thecal sac.

A posterior peridiscal osteophyte is seen at the C3-C4 level with anterior indentation of the cord. A mild posterior disc protrusion is seen at the C2-C3 level.

Ligamentum flavum hypertrophy is noted over the C3-C4 to the C6-C7 levels with tight canal over these levels.

- 2 - scan-00005

Anterior disc herniations are noted over the C3-C4 to D1-D2 levels. The cervical intervertebral discs show loss of water content.

Type II degenerative changes are noted in the C3 and C4 vertebral bodies adjacent to the C3-C4 intervertebral disc, which is reduced in height.

The C3-C4 and C4-C5 facet joints show degenerative changes.

The rest of 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 :

The MRI features are suggestive of :

1. A large posterior disc extrusion at the C4-C5 level with a large disc portion lying posterior to the C5 vertebral body with cord compresion. Altered signal of the cord at the C4-C5 and C5 levels suggests cord edema/ischemia.

2. Small posterior disc herniations at the C5-C6 and C6-C7 levels.

3. A posterior peridiscal osteophyte at the C3-C4 level, with cord compression.

4. Ligamentum flavum hypertrophy over the C3-C4 to the C6-C7 levels with tight canal over these levels.

5. Facetal arthropathy at the C3-C4 and C4-C5 levels.
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