Date : 00.00.00
Name of the Patient : Abc Xyzlmn / M / 58 yrs.
Referred by : Dr. Abc Xyzdha.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neck pain radiating to the LUE with paresthesias, giddiness and gait imbalance.
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.
There is loss of normal cervical curvature and loss of water content of the cervical intervertebral discs.
There is evidence of a large postero-central disc extrusion with peridiscal osteophytes, more to the left of the midline at the C5-C6 level. It is seen to compress upon the spinal cord and narrow the left neural foramen at this level. The cord at the C5-C6 level shows a subtle hyperintense signal on the Fast Scan (T2 *) images and this represent cord edema/ischemia. The disc appears reduced in height.
A postero-central disc herniation with peridiscal osteophytes is seen to indent the cord at the C4-C5 level. The joints of Luschka at this level show mild degenerative changes with slight bilateral neural foraminal narrowing, right more than left.
There is a small left postero-lateral disc herniation with peridiscal osteophytes narrowing the left neural foramen at the C6-C7 level. Postero-central disc protrusions are seen at the C2-C3 and C3-C4 levels.
The facet joints show degenerative changes bilaterally at the C5-C6 level and on the right side at the C6-C7 level.
Anterior disc herniations with peridiscal osteophytes are noted at the C4-C5, C5-C6 and C6-C7 levels.
The cervical vertebral bodies show areas of fatty replacement of normal marrow. The cervical intervertebral discs show loss of water content.
The rest of the joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
Small lymph nodes are seen adjacent to the carotid sheaths bilaterally.
The MRI features are suggestive of :
1. A large postero-central disc extrusion with peridiscal osteophytes, more to the left of the midline at the C5-C6 level with canal stenosis and cord compression with cord signal alteration at this level representing cord edema/ischemia.
2. A postero-central disc herniation with peridiscal osteophytes at the C4-C5 level.