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ke/bv/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzbali Shlmn / M / 36 yrs.
Referred by : Dr. Abc Xyzurke.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O neck pain radiating to BUE with paresthesias and weakness of BLE (left more than right) and BUE.
H/O fall from scooter.

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 screened with 5 mm thick T2 Weighted sagittal images.

OBSERVATION :

There is cerebellar tonsillar ectopia and the tip of the cerebral tonsil is seen to lie 1.2 cms below the foramen magnum, posterior to the cervical spinal cord.

The cervical spinal cord shows presence of a CSF signal intensity lesion on all the pulse sequences. This lesion is ill-defined and shows presence of septae and represents a syrinx. The syrnix is seen to extend from the C1-C2 to the D7 vertebral level.

The clivus is placed horizontally.

There are small posterior disc herniations with posterior peridiscal osteophytes at the C4-C5, C5-C6 and C6-C7 levels.
Small posterior disc herniations are also noted at the C2-C3 and C3-C4 levels. The cervical intervertebral discs show loss of water content.



The cervical vertebral bodies show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.

The atlanto-axial region is unremarkable.

The dorsal spinal cord appears to be of slightly smaller in calibre as compared to normal.

A small posterior disc herniation with peridiscal osteophytes is noted at the D11-D12 level.

IMPRESSION :

The MRI features are suggestive of :

1. Chiari malformation.

2. Small posterior disc herniations with posterior peridiscal osteophytes at the C4-C5, C5-C6 and C6-C7 levels.


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