Date : 00.00.00 Name of the Patient : Abc XyzAlmn / M / 70 yrs. Referred by : Dr. Abc Xyzah.Examination : M.R.I. of the Cervical Spine.CLINICAL PROFILE :C/O paresthesias in all four extremities with weakness and gait imbalance since October 0000.
MRI s/O demyelination with disc prolapse at the cervical level.
For follow up.
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.OBSERVATION :There is a right postero-lateral disc herniation with small peridiscal osteophytes at the C6-C7 level with antero-lateral indentation of the cord and right neural foraminal narrowing. Mild indentation upon the right C7 nerve root is noted. A small posterior disc bulge is seen at the C5-C6 level.There are postero-central disc protrusions at the C3-C4 and C4-C5 levels with anterior indentation of the thecal sac. The cervical spinal cord shows an area which is isointense to CSF, at the C3 and C3-C4 levels.
The C3-C4 facet joints show degenerative changes.
The cervical intervertebral discs show loss of water content.
The cervical vertebral bodies reveal 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.Incidental note is made of a mega cisterna magna.
The brain was screened with 5 mm thick T2 Weighted axial images and shows few small bright foci in the white matter in the right fronto-parietal lobes and these may be ischemic in etiology. Also seen is mild prominence of the cerebral cortical sulci and cerebellar folia bilaterally. IMPRESSION :The MRI features are suggestive of :1. Altered signal of the cervical spinal cord, at the C3 and C3-C4 levels would represent an area of myelomalacia.
2. A right postero-lateral disc herniation at the C6-C7 level indenting the right C7 nerve root.
Previous MRI was not available for comparision.