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ke/bv/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz R. Ghlmn / F / 37 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O neck pain radiating to the RUE with paresthesias since 3 years and difficulty in writing.
H/O pulmonary Kochs 9 months back. Received AKT.

EXAMINATION :

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.

OBSERVATION :

There is loss of normal cervical curvature and loss of water content of the cervical intervertebral discs.

A posterior disc herniation with posterior peridiscal osteophytes is seen at the C3-C4 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing, right more than left.

A posterior and right postero-lateral disc herniation is noted at the C4-C5 level with anterior indentation of the thecal sac and right neural foramen narrowing. Degeneration of the right joint of Luschka is noted with mild indentation upon the right C5 nerve root.

There is a small posterior disc herniation at the C5-C6 level and a right paracentral disc herniation at the C6-C7 level with anterior indentation of the thecal sac.

Posterior peridiscal osteophytes are noted at the C4-C5 and C5-C6 levels.
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The cervical vertebral bodies show normal signal intensity. The rest of 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.

IMPRESSION :

The MRI features are suggestive of :

1. A posterior disc herniation with posterior peridiscal osteophytes at the C3-C4 level.

2. A posterior and right postero-lateral disc herniation at the C4-C5 level with degeneration of the joints of Luschka on the right side and indentation upon the right C5 nerve root.

3. A small posterior disc herniation at the C5-C6 level.

4. A right paracentral disc herniation at the C6-C7 level.

5. Posterior peridiscal osteophytes at the C4-C5 and C5-C6 levels.

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