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sb/hs/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzbanu Slmn / F / 19 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O congenital, spasmodic torticollis on the left side with pain which has increased since 3 months.

EXAMINATION :

M.R.I of the cervical spine and sternocleidomastoid muscles 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.

5 mm thick STIR coronal images.

OBSERVATION :

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

There is scoliosis of the cervical spine with convexity to the left. The head is seen to be tilted to the right.

The right sternocleidomastoid muscle appears smaller in bulk as compared to the left and shows a hypointense signal on all the pulse sequences, suggesting fibrotic changes/fibrotic band (marked on the films by arrows). The left sternocleidomastoid muscle appears slightly bulky and shows normal signal.

Postero-central protruded discs are noted at the C3-C4, C4-C5 and C5-C6 levels.



Enlarged right submandibular lymph nodes are noted with a maximum transverse dimension of about 1.2 cms.

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. There is no cord compression.

The atlanto-axial region and the cervico-medullary junction are unremarkable.

IMPRESSION :

1. Scoliosis of the cervical spine with convexity to the left, with the head tilted to the right.

2. Decrease in bulk of the right sternocleidomastoid muscle with a hypointense signal may suggest fibrotic changes/fibrous band.

3. Postero-central protruded discs at the C3-C4, C4-C5 and C5-C6 levels.

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