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Date : 00.00.00

Name of the Patient : Abc Xyzram Salmn / M / 40 yrs.
Referred by : Dr. Abc Xyztel.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE:

C/O neck pain radiating to the LUE with tingling since 6-7 months.

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 loss of normal cervical curvature and loss of water content of the cervical intervertebral discs.

There is slight forward subluxation of the C4 over the C5 vertebra with a pseudo-posterior disc herniation at the C4-C5 level and anterior indentation of the thecal sac. The C4-C5 facet joint on the left side shows hypertrophic degenerative changes with left neural foraminal narrowing. A large posterior osteophyte is seen on the right side at this level with right neural foraminal narrowing.

A posterior disc herniation with peridiscal osteophyte is seen at the C3-C4 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The C3-C4 facet joints show hypertrophic degenerative changes, bilaterally, left more than right. The joints of Luschka also show degenerative changes, bilaterally.

Diffuse, posterior disc herniations with peridiscal osteophytes are noted at the C2-C3, C5-C6 and C6-C7 levels with anterior indentation of the thecal sac. The C2-C3 and C5-C6 facet joints show degenerative changes.
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- 2 - scan-00007

Fatty marrow changes are seen in the upper cervical vertebrae with slight wedging of the C5 and C6 vertebral bodies.

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

The cervical spinal cord and visualized upper dorsal spinal cord show normal signal intensity.

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

IMPRESSION :

1. Slight forward subluxation of the C4 over the C5 vertebra with a pseudo-posterior disc herniation at the C4-C5 level. There is a hypertrophic facetal arthropathy on the left side with a large osteophyte is seen on the right side at this level.

2. A posterior disc herniation with peridiscal osteophyte
at the C3-C4 level with hypertrophic facetal arthropathy, bilaterally, left more than right at this level.

3. Diffuse, posterior disc herniations with peridiscal osetophytes at the C2-C3, C5-C6 and C6-C7 levels with facetal arthropathy at these levels.


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