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sb/ke/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzimal lmn / M / 40 yrs.
Referred by : Dr. Abc Xyzhta.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

Known C/O rheumatoid arthritis since 5 years.
C/O severe neck pain with dysphagia since 2 months.

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.

OBSERVATION :

There is reduction in height and loss of water content of the cervical intervertebral discs.

There is slight anterior translation of nearly all the proximal cervical vertebrae over the corresponding distal vertebra.

There is invagination of the odontoid process through the foramen magnum with resultant indentation on the cervico-medullary junction. The peridental fat is not well identified. Intermediate signal intensity lesion is noted in the peridental region on the T1 Weighted images which appears hyperintense on the T2 Weighted and Fast Scan (T2 *) images.

Small posterior peridiscal osteophytes are noted in the cervical region. There is also ligamentum flavum hypertrophy at the C1-C2, C2-C3, C3-C4, C4-C5 and C6-C7 levels with resultant effacement of the posterior subarachnoid space.


Type III degenerative marrow changes are noted adjacent to the C2-C3, C3-C4 and C6-C7 intervertebral discs.

The rest of 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 left vertebral artery appears hypoplastic.

IMPRESSION :

1. Slight anterior translation of nearly all the proximal cervical vertebrae over the corresponding distal vertebra.

2. Basilar invagination with tip of the odontoid process indenting the cervico-medullary junction.

3. Altered signal in the peridental region may either represent pannus or degenerative fibrous tissue.

4. Small posterior peridiscal osteophytes are noted in the cervical region with ligamentum flavum hypertrophy at the C1-C2, C2-C3, C3-C4, C4-C5 and C6-C7 levels.

These changes may either be the sequelae of rheumatoid arthritis with secondary degenerative changes or may be primarily degenerative in etiology.


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