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hs/sb
Date : 00.00.00

Name of the Patient : Abc Xyz. Glmn / M / 70 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE:

C/O wasting of the RUE since 1 1/2 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.

4 mm thick STIR coronal images.

OBSERVATION :

There are large posterior peridiscal osteophytes (hard discs) and posterior disc bulges indenting the cord at the C3-C4 and C4-C5 levels. There is bilateral neural foraminal narrowing at these levels. The cord over the C3-C4 to the C4-C5 level shows hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images and which may represent cord edema/ischemia.

Posterior disc bulges with peridiscal osteophytes are noted at the C5-C6 and C6-C7 levels.

The facet joints at the C2-C3, C3-C4 and C4-C5 levels show hypertrophic degenerative changes bilaterally.

The C3-C4, C4-C5, C5-C6 and C6-C7 intervertebral discs are decreased in height. The cervical intervertebral discs show loss of water content. The cervical vertebral bodies show areas of fatty replacement of normal marrow.
..2/.







There are anterior disc herniations with peridiscal osteophytes over the C3-C4 to C6-C7 levels.

The odontoid process is irregularly defined and this may be due to degenerative changes (?? pannus). A mass lesion which is predominantly hypointense with a few hyperintense areas within it on the STIR images is noted in the posterior soft tissues in the neck on the right side. This is most likely a fat containing tumor.

Also seen are soft tissue intensity lesions in the upper lobes of both lungs.

IMPRESSION :

The MRI features are suggestive of large posterior peridiscal osteophytes with posterior disc bulges at the C3-C4 and C4-C5 levels with cord edema/ischemia over the C3-C4 to the C4-C5 level. Also seen is canal stenosis at the C3-C4 and C4-C5 levels.

Smaller posterior disc bulges with peridiscal osteophytes are noted at the C5-C6 and C6-C7 levels.
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    • Interventional Pain Procedure Templates
    • The Ultimate Guide to Rapid Reporting for FRCR 2B
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