Date : 00.00.00
Name of the Patient : Abc Xyzn H. lmn / F / 40 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neckpain with giddiness and pain in BLE since 1 year.
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 slight loss of water content of the upper cervical intervertebral discs.
There is evidence of cerebellar tonsillar herniation through the foramen magnum with the tip of the tonsils lying at about the C2 vertebral level. Slight hypertrophy of the transverse ligament is noted indenting the cervico-medullary junction anteriorly. The fourth ventricle is mildly dilated with prominent cerebellar folia. The tip of the odontoid process is seen at the level of the foramen magnum.
A congenital block D2/D3 vertebra is noted.
There is a small postero-central protruded disc with peridiscal osteophyte at the C4-C5 level indenting the dural theca anteriorly.
A postero-central and left postero-lateral disc herniation with peridiscal osteophyte is noted at the C5-C6 level with left neural foraminal narrowing and indentation on the traversing left C6 nerve root.
The cervical vertebral bodies and the remaining 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 is unremarkable.
Cerebellar tonsillar herniation through the foramen magnum with congenital block D2/D3 vertebra suggest Chiari I malformation. Mild dilatation of the fourth ventricle is also noted with prominent cerebellar folia.