Date : 00.00.00
Name of the Patient : Abc Xyz Mlmn / M / 69 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
H/O fall 4 months back with C/O backache radiating to the LLE.
Now C/O weakness of the LLE since 15 days.
M.R.I of the cervical spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and Fast Scan (T2 *) axial images.
The dorsal spine was scanned with 4 mm thick T2 Weighted sagittal images and 5 mm thick T1 Weighted and T2 Weighted axial images through the region of interest.
Posterior disc herniations with peridiscal osteophytes are seen to indent the cord and narrow both neural foramina at the C4-C5, C5-C6 and C6-C7 levels.
A postero-central disc protrusion with peridiscal osteophytes is seen to indent the thecal sac at the C3-C4 level.
Ligamentum flavum hypertrophy is noted at the C4-C5 and C5-C6 levels. The C3-C4, C4-C5 and C5-C6 facet joints show degenerative changes.
The normal flow void signal within the right vertebral artery is not well-visualized, ? hypoplastic artery.
A small posterior disc herniation with peridiscal osteophytes is seen to indent the cord at the D10-D11 level. Severe ligamentum flavum hypertrophy with compression upon the cord is also seen at this level. The cord at this level shows a hyperintense signal on the T2 Weighted images and this may represent cord edema/ischemia. The D10-D11 facet joints show degenerative changes with severe canal stenosis.
Mild ligamentum flavum hypertrophy is noted at the D11-D12 level.
Mild posterior disc bulges with small peridiscal osteophytes are noted in the upper and mid-dorsal region.
Anterior disc herniations with peridiscal osteophytes are noted in the cervico-dorsal region.
The cervico-dorsal intervertebral discs show loss of water content.
The cervico-dorsal vertebral bodies are unremarkable.
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. A small posterior disc herniation with peridiscal osteophytes at the D10-D11 level with severe ligamentum flavum hypertrophy, facetal arthropathy and severe canal stenosis at this level.
- 3 - scan-00006
2. Altered signal of the cord at the D10-D11 level is suggestive of cord edema/ischemia.
3. Posterior disc herniations with peridiscal osteophytes at the C4-C5, C5-C6 and C6-C7 levels.
4. A postero-central disc protrusion with peridiscal osteophytes at the C3-C4 level.
5. Ligamentum flavum hypertrophy at the C4-C5 and C5-C6 levels and facetal arthropathy at the C3-C4, C4-C5 and C5-C6 levels.