Date : 00.00.00
Name of the Patient : Abc Xyzh Khedlmn / M / 16 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O radicular pain to the LLE with tingling and dragging of the LLE since 3 years.
M.R.I of the cervical spine was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and Fast Scan (T2 *) axial images.
There is a small posterior disc herniation at the C5-C6 level with anterior indentation of the thecal sac.
Small posterior peridiscal osteophytes are noted at the C3-C4, C4-C5 and C5-C6 levels.
The C4-C5 and C5-C6 intervertebral discs show loss of water content. The C4/C5 vertebrae appear as a congenital block vertebra.
There are enlarged lymph nodes in the deep cervical chain bilaterally.
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 over C6 to D1 vertebral levels appears smaller in calibre but reveals normal signal intensity.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
1. Congenital block C4-C5 vertebra.
2. A small posterior disc herniation at the C5-C6 level.
3. Slight atrophy of the cervico-dorsal spinal cord over C6 to D1 vertebral levels, without change in signal intensity. Anterior horn cell disease should be ruled out.