Date : 00.00.00
Name of the Patient : Abc Xylmn / M / 62 yrs.
Referred by : Dr. Abc Xyzankhla.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neckpain with pain radiating to the RUE and LLE for which patient was operated in August 0000 (surgical details unavailable).
Now C/O weakness in the LLE and index finger and thumb of both hands.
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. Slight retroplacement of the C4 vertebra in relation to the C3 and C5 vertebrae is noted.
There is evidence of laminectomy of the C2 to C6 vertebrae with post-operative changes in the soft tissues in the posterior cervical region over these levels. Slight retroplacement of the thecal sac is noted over these levels. A very small, approximately 8.0 x 4.0 mms sized collection is noted posterior to the thecal sac at the C3-C4 level (scans 102.4, 105.7).
Posteriorly bulging discs with fairly large posterior peridiscal osteophytes are noted over the C3-C4 to C6-C7 levels, indenting the dural theca anteriorly. Slight bilateral neural foraminal narrowing is noted at the C3-C4, C4-C5 and C5-C6 levels.
The cervical spinal cord appears slightly smaller in calibre over the C3 to C5 vertebral levels and shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images, centrally, over these levels.
The facet joints at the C3-C4, C4-C5, C5-C6 and C6-C7 levels bilaterally show hypertrophic degenerative changes.
The C6 vertebral body shows a focal hypointense signal on the T1 Weighted images to the right of the midline, posteriorly. This lesion appears hyperintense on the T2 Weighted images and may represent bone edema/focal hemangioma.
The rest of the cervical vertebral bodies show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
1. Post-operative status.
2. Posteriorly bulging discs with fairly large posterior peridiscal osteophytes over the C3-C4 to C6-C7 levels, with bilateral neural foraminal narrowing at the C3-C4, C4-C5 and C5-C6 levels.
3. Atrophy of the cervical spinal cord over the C3 to C5 vertebral levels with altered signal, centrally, suggesting myelomalacic changes.
4. Hypertrophic facetal arthropathy at the C3-C4, C4-C5, C5-C6 and C6-C7 levels bilaterally.