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hs/ke/rg/nl
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.

EXAMINATION :

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.

OBSERVATION :

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.

IMPRESSION :

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.
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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.

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