Date : 00.00.00
Name of the Patient : Abc XyzH. lmn / M / 32 yrs.
Referred by : Dr. Abc Xyzcha.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neck pain radiating to the RUE with paresthesias since 6-7 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 loss of normal cervical lordosis and loss of water content of the cervical intervertebral discs.
Minimal forward translation of the C7 over the D1 vertebra is noted.
There is a right paracentral disc herniation at the C5-C6 level, indenting the dural theca anteriorly. The disc material is seen to lie in the right neural foramen with indentation upon the right C6 nerve root (scans 105.13, 106.5) and the spinal cord. A left postero-lateral disc bulge with peridiscal osteophytes is noted at the C5-C6 level with slight left neural foraminal narrowing.
Small posterior disc bulges with peridiscal osteophytes are noted at the C4-C5, C6-C7 and C7-D1 levels.
The joints of Luschka at the C5-C6 and C6-C7 levels show mild degenerative changes.
Slight facetal hypertrophy is noted at the C3-C4 and C4-C5 levels on the left.
The upper cervical vertebral bodies show spotty fatty marrow changes. The remaining 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. A right paracentral disc herniation at the C5-C6 level with disc material seen in the right neural foramen indenting the spinal cord and the right C7 nerve root.
2. Small posterior disc bulges with peridiscal osteophytes
at the C4-C5, C6-C7 and C7-D1 levels.