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sb/hs/nl.
Date : 00.00.00

Name of the Patient : Abc Xyzundar Rlmn / F / 52 yrs.
Referred by : Dr. Abc Xyz Shah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE:

C/O neckpain since 1 month which has increased since 4 days.
C/O radicular pain to the RUE with paresthesias.

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 lordosis and loss of water content of the cervical intervertebral discs.

There is a fairly large, left postero-lateral extruded disc with peridiscal osteophytes at the C4-C5 level with thecal sac compression and indentation on the left C5 nerve root.

A fairly large, postero-central and right paracentral extruded disc with peridiscal osteophytes is noted at the C5-C6 level with thecal sac compression and indentation on the right C6 nerve root. Superior and inferior migration of the disc fragment is noted into the right lateral recesses of the C5 and C6 vertebrae, respectively.

Small postero-central protruded discs are noted at the C2-C3 and C3-C4 levels and a small right paracentral protruded disc is noted at the C6-C7 level. A postero-central disc protrusion is seen at the D3-D4 level.


Spotty fatty marrow changes are noted in the cervical vertebrae.

The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.

The cervical spinal cord shows normal signal intensity.

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

IMPRESSION :

1. A fairly large, left postero-lateral extruded disc with peridiscal osteophytes at the C4-C5 level with indentation on the left C5 nerve root.

2. A fairly large, postero-central and right paracentral extruded disc with peridiscal osteophytes at the C5-C6 level with indentation on the right C6 nerve root. Superior and inferior migration of the disc fragment is noted into the right lateral recesses of the C5 and C6 vertebrae, respectively.

3. Small postero-central protruded discs at the C2-C3 and C3-C4 levels.

4. A small right paracentral protruded disc at the C6-C7 level.

5. A postero-central disc protrusion at the D3-D4 level.






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