Date : 00.00.00
Name of the Patient : Abc Xyzokbandhu Slmn / M / 26 yrs.
Referred by : Dr. Abc Xyzah / Dr. Abc Xyz
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
H/O fall 1 1/2 years ago with ? spinal surgery done. Details not available.
C/O neck pain radiating to the LUE with paresthesias, weak grip and slight wasting of the LUE.
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 loss of water content of the cervical intervertebral discs.
Suspicious surgical intervention is noted at the C5-C6 and C6-C7 disc levels.
Small posterior disc bulges with peridiscal osteophytes are noted at the C3-C4, C4-C5 and C6-C7 levels.
Small posterior disc herniations with peridiscal osteophytes is noted at the C5-C6 level with slight left neural foraminal narrowing.
Slight facetal hypertrophy is noted at the C5-C6 and C6-C7 levels on the left.
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.
1. ? Post-operative changes at the C5-C6 and C6-C7 disc levels.
2. Small posterior disc bulges with peridiscal osteophytes at the C3-C4, C4-C5 and C6-C7 levels.
3. Small posterior disc herniations with peridiscal osteophytes at the C5-C6 level.
4. Slight facetal hypertrophy at the C5-C6 and C6-C7 levels on the left.