Date : 00.00.00
Name of the Patient : Abc Xyz Agrlmn / M / 30 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neck pain radiating to the RUE with numbness since June 0000 with headaches.
Alleged H/O vehicular accident prior to this.
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.
There is fracture with anterior wedging of the D2 vertebral body. A Schmorls node is identified on the inferior surface of the D2. This vertebral body however shows normal signal intensity. There is a posterior disc herniation at the D2-D3 level with anterior indentation of the thecal sac.
There are small postero-central disc herniations at the C4-C5 and the C5-C6 levels with anterior indentation of the thecal sac.
The cervical vertebral bodies and the intervertebral discs show normal signal intensity. 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 MRI features are suggestive of :
1. Fracture with anterior wedging of the D2 vertebral body with a posterior disc herniation at the D2-D3 level.
2. Small postero-central disc herniations at the C4-C5 and the C5-C6 levels.