Date : 00.00.00
Name of the Patient : Abc Xyzr Almn / M / 35 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O weakness of BUE (left more than right) and BLE with dragging of the LLE since 6 months.
Alleged H/O vehicular accident 2 years back with loss of consciousness for an hour.
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 partial occipitalization of the atlas.
The tip of the odontoid process is seen to lie at the level of the foramen magnum. There is atlanto-dens subluxation with the atlanto-dens interval measuring approximately 5 mms. The postero-superior aspect of the odontoid process is seen to compress upon the cervico-medullary junction which shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images and is isointense to cord on the T1 Weighted images. This would represent cord edema/gliosis. The clivus is placed more horizontally as compared to normal.
Posterior disc herniations are noted at the C2-C3, C4-C5 and C5-C6 levels with anterior indentation of the thecal sac.
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 brain was screened with 5 mm thick T2 Weighted axial images and shows mild fullness of both the lateral ventricles and inflammatory changes in the maxillary sinuses bilaterally (right more than left) and sphenoid sinus.
1. Partial occipitalization of the atlas with the tip of the odontoid process seen to lie at the level of the foramen magnum with atlanto-axial dislocation and atlanto-dens subluxation with atlanto-dens interval measuring 5 mms.
2. Altered signal at the cervico-medullary junction
represents cord edema/gliosis.