Date : 00.00.00
Name of the Patient : Abc Xyz Tibrlmn / M / 21 yrs.
Referred by : Dr. Abc Xyzrani / Dr. Abc Xyzkar.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
Alleged H/O RTA on 00.00.00, C/O neckpain radiating to BLE and RUE with paresthesias since then. H/O bilateral Erls palsy since birth.
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.
3 mm thick T2 Weighted coronal images (with fat saturation).
There is slight loss of water content of the C2-C3 and C3-C4 intervertebral discs.
There is a transverse, undisplaced fracture through the base of the odontoid process. The atlanto-dens interval is normal. There is no cord compression or cord signal alteration. The atlanto-occipital joints are unremarkable. Minimal fluid is noted in the left atlanto-occipital joint.
Ill-defined, hyperintense signal on the Fast Scan (T2 *) images in the left posterior paraspinal soft tissues over the C5-C6 to the C7-D1 level may represent soft tissue injury.
There is a probable avulsion of the right C7 nerve root with a pseudomeningocele along the right C7 nerve root and in the right neural foramen at the C6-C7 level (scans 103.6, 102.6, 105.18, 19). The cervical spinal cord at the C7 and D1 vertebral levels appears slightly smaller in calibre than normal without an obvious change in its signal intensity.
Linear, hypointense signal on the T1 Weighted images along the superior cortical endplates of the C4 and C5 vertebral bodies which appears isointense to normal vertebral bodies on the T2 Weighted images may be the sequelae of previous trauma.
Small posterior peridiscal osteophytes are noted at the C4-C5 and C5-C6 levels.
The rest of the cervical vertebral bodies and the remaining intervertebral discs show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
The cervical spinal cord shows normal signal intensity.
The cervico-medullary junction is unremarkable.
1. Undisplaced, transverse fracture through the base of the odontoid process with minimal fluid in the left atlanto-occipital joint.
2. Avulsion of the right C7 nerve root with a pseudomeningocele as described.
3. Atrophy of the cervico-dorsal spinal cord at the C7 and D1 vertebral bodies.