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Date : 00.00.00

Name of the Patient : Abc Xyzn Plmn / M / 67 yrs.
Referred by : Dr. Abc Xyze.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE:

H/O fall on 00.00.00 with C6 # and C5/C6 dislocation.
C/O swelling over LUE and LLE with weakness/paresthesias in the LUE 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 reduction in the height of the C5-C6 intervertebral disc which appears hypointense on the T1 Weighted images and turns hyperintense on the T2 Weighted images.

The C5 and C6 vertebral bodies show hypointense areas on the T1 Weighted images which are seen to turn hyperintense on the T2 Weighted images.

There is a postero-central disc herniation at the C4-C5 level with anterior indentation of the thecal sac.

A left postero-lateral disc herniation is noted at the C5-C6 level with left neural foraminal narrowing and indentation on the left C6 nerve root. The spinal cord at the C5-C6 and C6 vertebral levels shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images which is isointense to normal cord on the T1 Weighted images.

Posterior peridiscal osteophytes are noted at the C3-C4, C4-C5 and C5-C6 levels.
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The C3-C4 and C4-C5 facet joints show mild degenerative changes.

Probable fracture of the posterior elements of the C5 vertebra is noted (scans 104.13).

The cervical intervertebral discs except for C5-C6 disc show loss of water content.

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.

The flexion and extension images of the cervical spine do not reveal any significant feature of note.

IMPRESSION :

The MRI features are suggestive of :

1. Altered signal in the C5 and C6 vertebral bodies may suggests bone edema/bruise in the given clinical setting of trauma. Probable fracture of the posterior elements of C5 vertebra is noted.

2. A postero-central disc herniation at the C4-C5 level.

3. A left postero-lateral disc herniation at the C5-C6 level with left neural foraminal narrowing and indentation on the left C6 nerve root.

4. Altered signal of the cord at the C5-C6 and C6 vertebral levels would represent cord edema/contusion.

5. Posterior peridiscal osteophytes at the C3-C4, C4-C5 and C5-C6 levels.

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