Date : 00.00.00
Name of the Patient : Abc Xyz D. Plmn / M / 55 yrs.
Referred by : Dr. Abc Xyzrges.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
Alleged H/O fall from the bed with loss of consciousness for 1 day on 00.00.00.
C/O gait imbalance with mild weakness of BUE and BLE since then.
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 cervical intervertebral discs show loss of water content.
There is a posterior disc herniation at the C3-C4 level with anterior indentation of the cord.
Small posterior disc bulges are noted at the C4-C5, C5-C6 levels.
Posterior peridiscal osteophytes are seen at the C3-C4, C4-C5 and C5-C6 levels.
Hyperintense signal on the T1 Weighted and T2 Weighted images in the C6-C7 intervertebral disc may represent calcification.
The cervical vertebral bodies show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
The cervical spinal cord reveals normal signal intensity.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
The brain was screened with 5 mm thick T2 Weighted axial images and 5 mm thick FLAIR coronal images which shows hyperintense areas in the periatrial deep white matter. Mild cerebral and cerebellar atrophy and left maxillary sinusitis is noted. Fullness of both the lateral and the third ventricles is noted. The fourth ventricle is normal. Left mastoiditis is noted.
1. A posterior disc herniation at the C3-C4 level.
2. Posterior peridiscal osteophytes at the C3-C4, C4-C5 and C5-C6 levels with posterior disc bulges at the C4-C5 and C5-C6 levels.