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sb/ke/nl/nl
Date : 00.00.00

Name of the Patient : Abc XyzSlmn / M / 44 yrs.
Referred by : Dr. Abc Xyzhry.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O pain in the LLE.
H/O spinal surgery on 29th July 0000 (details not available).

EXAMINATION :

M.R.I of the cervical spine was performed using the following parameters :

4 mm thick T1 Weighted and T2 Weighted sagittal images.

4 mm thick T1 Weighted and T2 Weighted axial images.

4 mm thick T1 Weighted sagittal images were also obtained in flexion and extension.

OBSERVATION :

There is evidence of operative intervention in the posterior cervical and suboccipital region with susceptibility artifacts in the soft tissues in the posterior cervical region at that level.

There is loss of water content of the cervical intervertebral discs.

There is still seen a fracture of odontoid process through its mid portion with the base of the fractured fragment tilted posteriorly. Slight anterior subluxation of this fractured fragment with the anterior arch of C1 over the rest of the odontoid process is noted. The distance between the arch and the dens is maintained.


The cervical spinal cord at C1 and C2 vertebral bodies is atrophied and shows a hyperintense signal on the proton and T2 Weighted images suggesting gliotic/myelomalacic changes.

Small postero-central protruded disc with peridiscal osteophytes are noted at the C2-C3, C3-C4 and C5-C6 levels.

Small postero-central disc herniation with peridiscal osteophyte is noted at the C4-C5 level.

The cervical vertebral bodies show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.

There is no significant change noted in the relation of the fractured fragment and the rest of the odontoid process on the flexion images. On the extension images, however the fractured tip comes more towards the normal alignment with the rest of the odontoid process.

IMPRESSION :

1. Post-operative status.

2. Fracture of the odontoid process through its mid portion with slight anterior translation of the fractured fragment and the anterior arch of C1 over the rest of the odontoid process.

3. Atrophy of the cervical spinal cord at the C1 and C2 vertebral levels with altered signal suggesting gliotic/myelomalacic changes.
..3/.













- 3 - Scan-00005


4. Small postero-central protruded discs with peridiscal osteophytes at the C2-C3, C3-C4, C5-C6 and C6-C7 levels.

5. Small postero-central disc herniation with peridiscal osteophytes at the C4-C5 level.

As compared to the previous MRI (study no:502) dated 00.00.00, there is no significant change noted.


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