Date : 00.00.00
Name of the Patient : Abc Xyz Dlmn / F / 72 yrs.
Referred by : Dr. Abc Xyznghal.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O radicular pain and paresthesias in the LLE, slipping off of chappals from the left leg with gait imbalance and loss of sensations in the LLE.
Alleged H/O fall 2 months back.
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 lordosis and loss of water content of the cervical intervertebral discs. Slight retroplacement of the C5 over the C6 vertebra is noted. The C5-C6 intervertebral disc is decreased in height.
Postero-central disc herniations with peridiscal osteophytes are noted at the C4-C5 and C5-C6 levels, indenting the cervical spinal cord anteriorly.
A small postero-central protruded disc is noted at the C3-C4 level.
Slight facetal hypertrophy is noted at the C4-C5, C5-C6 and D1-D2 levels with ligamentum flavum prominence at the C4-C5 and C5-C6 levels.
Spotty fatty marrow changes are noted in the upper cervical vertebral bodies.
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.
Incidentally noted is an empty sella which is enlarged.
1. Postero-central disc herniations with peridiscal osteophytes at the C4-C5 and C5-C6 levels, indenting the cervical spinal cord anteriorly.
2. A small postero-central protruded disc at the C3-C4 level.
3. Slight facetal hypertrophy at the C4-C5, C5-C6 and D1-D2 levels with ligamentum flavum prominence at the C4-C5 and C5-C6 levels.
4. Canal stenosis at the C4-C5 level and a tight canal at the C5-C6 level.