Date : 00.00.00
Name of the Patient : Abc Xyzlmn / F / 25 yrs.
Referred by : Dr. Abc Xyzar.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
H/O vehicular accident on 00.00.00.
C/O quadriplegia since then.
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. Minimal forward translation of the C5 over the C6 vertebra is noted.
There are small posterior disc herniations at the C4-C5 and C5-C6 levels with anterior compression of the spinal cord.
The spinal cord over the C2 to the D1 levels shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images which is isointense to normal cord on the T1 Weighted images. A small hypointense area is seen at the C5-C6 level which may represent altered blood.
Intermediate signal intensity lesion is seen in the anterior epidural space at the C2 and C3 levels on the T1 Weighted images which turns hyperintense on the T2 Weighted images and may represent altered blood.
Hyperintense areas are seen in the prevertebral soft tissue from the level of the clivus to the C4 vertebral levels which represents edema/contusion/hematoma.
Small posterior disc bulges are noted at the C3-C4 and C6-C7 levels.
- 2 - scan-00003
Hyperintense signal on the T2 Weighted images in the C2-C3 disc anteriorly, C4-C5 disc posteriorly and C5-C6 disc superiorly may represent traumatic discs.
Fracture of posterior elements of C5 is noted. The fat planes between the muscles in the posterior paraspinal region, more on the right are effaced, due to soft tissue injury.
The rest of the cervical vertebral bodies and the remaining intervertebral discs show normal signal intensity. The joints of Luschka and paravertebral soft tissues are unremarkable.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
In a known C/O trauma, the MRI features are suggestive of :
1. Altered signal of the cord over the C2 to the D1 levels represents cord edema/contusion. A haemorrhagic focus is noted at the C5-C6 level, on the right.
2. Altered signal in the anterior epidural space at the C2 and C3 levels and in the prevertebral soft tissues represent altered blood.
3. Probable traumatic rupture of the C2-C3, C4-C5 and C5-C6 discs with posterior disc herniations at the C4-C5 and C5-C6 levels.
4. Fracture of the posterior elements of C5 (spinous process) with minimal forward translation of C5 over C6 vertebra.