Ssb.ke.nl.rg.can No : 00007 Date : 00.00.00
Name of the Patient : Abc Xyz Kilmn / M / 21 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O headaches with neckpain and vomiting since 00.00.00.
H/O right sided pleural effusion. Received AKT.
(? spinal surgery for tumor, surgical details not available).
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.
4 mm thick T2 Weighted (with fat saturation) coronal images.
There is loss slight loss of water content of the upper cervical intervertebral discs.
Small posterior disc bulges are noted at the C3-C4, C4-C5 and C5-C6 levels.
Degenerative changes of the joints of Luschka are noted at the C3-C4, C4-C5 and C5-C6 levels, bilaterally.
The cervical vertebral bodies and the remaining intervertebral discs show normal signal intensity. 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.
A hyperintense signal on all the pulse sequences is noted in the right internal jugular vein, which appears slightly dilated at the base of the neck.
Incidentally noted is a large, right sided pleural effusion.
An intermediate signal intensity lesion is seen on the T1 Weighted images in the right neural foramen at the D3-D4 level which is seen to turn hyperintense on the T2 Weighted images and would require further evaluation.
1. Small posterior disc bulges at the C3-C4, C4-C5 and C5-C6 levels.
2. Degenerative changes of the joints of Luschka at the C3-C4, C4-C5 and C5-C6 levels, bilaterally.
3. A large, right sided pleural effusion.
4. H/O surgery for spinal tumor 4 years back of which details are not available).