Date : 00.00.00
Name of the Patient : Abc Xyzmar Milmn / M / 38 yrs.
Referred by : Dr. Abc Xyztel.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
H/O benign teratoma of mediastinum, excised 14 years ago.
C/O paresthesias with weakness of the RLE since 1 month with complete weakness of the RUE and RLE since 10 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.
Postero-central disc herniations with peridiscal osteophytes are seen to indent the thecal sac at the C3-C4 and C5-C6 levels.
There is a small postero-central disc herniation at the C4-C5 level. The left facet joint shows degenerative changes at this level.
A posterior disc bulge is noted at the C6-C7 level.
The cervical intervertebral discs show loss of water content.
The cervical vertebral bodies 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. Postero-central disc herniations with peridiscal osteophytes at the C3-C4 and C5-C6 levels.
2. A small postero-central disc herniation at the C4-C5 level.
3. Facetal arthropathy at the C4-C5 level on the left side.