Date : 00.00.00
Name of the Patient : Abc XyzKlmn / M / 57 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O pain in the nape of the neck since several years.
C/O radicular pain to the RUE since 15 days.
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 loss of normal cervical lordosis and loss of water content of all the cervical intervertebral discs.
There is slight retroplacement of the C4 over the C5 vertebral bodies.
There is a fairly large postero-central disc herniation at the C4-C5 level with ventral indentation of the thecal sac and the spinal cord. The spinal cord appears semilunar in shape and there is a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images within the spinal cord at this level suggesting cord edema/ischemia.
Postero-central disc herniations with small peridiscal osteophytes are seen at the C5-C6, C6-C7 and C7-D1 levels, more to the right of the midline at the C7-D1 level. There is also cord compression over these levels.
There is a small, left paracentral protruded disc with peridiscal osteophyte at the C2-C3 level.
There appears to be ossification of the posterior longitudinal ligament extending from the C4-C5 to C7 vertebral levels.
There is slight hypertrophy of the facet joints on the left side at the C4-C5 and C5-C6 levels.
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.
1. Slight retroplacement of the C4 over the C5 vertebral bodies.
2. A fairly large postero-central disc herniation at the C4-C5 level with cord signal alteration at this level suggesting cord edema/ischemia.
3. Postero-central disc herniations with small peridiscal osteophytes at the C5-C6, C6-C7 and C7-D1 levels.
4. Ossification of the posterior longitudinal ligament extending from the C4-C5 to C7 vertebral levels.
5. Tight cervical canal over the C4-C5 to the C7-D1 levels.