Date : 00.00.00
Name of the Patient : Abc Xyzhalmn / M / 50 yrs.
Referred by : Dr. Abc Xyzraf.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
H/O fall of heavy weight over the head 7 years back.
C/O progressive weakness of all four extremities, giddiness and loss of speech (since 4 years) since 6 years.
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 brain was screened with 5 mm thick T2 Weighted axial images.
There is slight anterior wedging of the C6 vertebral body without change in signal intensity. There is loss of normal cervical lordosis and loss of water content of the cervical intervertebral discs.
Small posterior peridiscal osteophytes are noted at the C3-C4 and C5-C6 levels.
A small posterior disc bulge with peridiscal osteophytes is noted at the C6-C7 level, indenting the dural theca anteriorly.
The left sided joint of Luschka at the C5-C6 level shows slight degenerative changes with left neural foraminal narrowing.
Slight hypertrophy of the facet joints is noted at the C4-C5 and C5-C6 levels.
The cervical vertebral bodies show spotty fatty marrow changes. The rest of the joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
The cervical spinal cord reveals normal signal intensity.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
The T2 Weighted axial images of the brain reveal a lacune in the left lentiform nucleus with mild cerebral cortical atrophy. Note is made of left maxillary sinusitis.
1. Slight anterior wedging of the C6 vertebral body without change in signal intensity.
2. Small posterior peridiscal osteophytes at the C3-C4 and C5-C6 levels.
3. A small posterior disc bulge with peridiscal osteophytes at the C6-C7 level.
4. Degenerative changes of the left sided joint of Luschka at the C5-C6 level.
5. Slight hypertrophy of the facet joints at the C4-C5 and C5-C6 levels.