Date : 00.00.00
Name of the Patient : Abc Xyzh Sanzlmn / M / 71 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O tingling with weakness and wasting of the RUE since 4 months.
EMG s/o right C5, C6 & C7 lesion at the proximal level, probably at the root on brachial plexus level.
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.
The cervical intervertebral discs show loss of water content and the C3-C4, C4-C5 and C5-C6 are reduced in height. There is clockwise rotation of the mid cervical vertebrae.
There are posterior peridiscal osteophytes at the C3-C4, C4-C5, C5-C6, C6-C7 and C7-D1 levels with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. There is indentation on the cord over the C3-C4 to the C5-C6 levels with ligamentum flavum hypertrophy and a tight cervical canal. The cervical spinal cord over these levels appear triangular in shape.
The spinal cord at C3-C4, C4-C5 and C5-C6 levels shows subtle hyperintense signal on the Fast Scan (T2 *) images and is isointense to normal cord on the T1 Weighted images suggesting of cord edema/ischemia.
The C3-C4, C4-C5 and C5-C6 facet joints on the right side show degenerative changes.
Type I/II degenerative changes are seen in the C3, C4, C5 and C6 vertebrae adjacent to the intervertebral discs.
The cervical vertebrae show diffuse fatty change.
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.
1. Posterior peridiscal osteophytes at the C3-C4, C4-C5, C5-C6, C6-C7 and C7-D1 levels with indentation on the cord over the C3-C4 to the C5-C6 levels and ligamentum flavum hypertrophy and a tight cervical canal over these levels.
2. Altered signal of the cervical spinal cord at the C3-C4, C4-C5 and C5-C6 levels suggesting cord edema/ischemia.