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ke/sb/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzra Kotlmn / M / 33 yrs.
Referred by : Dr. Abc Xyzzzare.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O sudden onset of weakness of BUE with inability to lift up the LUE since 00.00.00.
H/O fall prior to this.

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 retroplacement of the C5 over the C6 vertebral body with anterior wedging of C5 and anterior indentation upon the cord. The spinal cord at this level shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images which is iso to hypointense to the normal cord on the T1 Weighted images and would represent cord edema/ischemia/contusion.

There is replacement of the normal marrow of the C5 vertebral body by hypointense signal on the T1 Weighted images which is seen to turn heterogeneously hyperintense on the T2 Weighted and Fast Scan (T2 *) images. There is fracture of the lamina of the C4 vertebra bilaterally and the spinous process.

A left paracentral disc herniation is seen at the C5-C6 level with antero-lateral indentation of the cord and left neural foraminal narrowing. Mild indentation upon the left C6 nerve root is noted.

The cervical intervertebral discs show loss of water content.
..2/.







The rest of the cervical vertebral bodies show normal signal intensity. The joints of Luschka and the visualized paravertebral soft tissues are unremarkable. Probable small prevertebral soft tissue lesion is noted (? hematoma/contusion)

The atlanto-axial region and the cervico-medullary junction are unremarkable.

IMPRESSION :

The MRI features are suggestive of :

1. Retroplacement of the C5 over the C6 vertebral body with altered signal of the C5 vertebral body represents bone edema/bruise, probably due to previous trauma, in the given clinical setting.

2. Altered signal of the spinal cord at the C5 and C6 vertebral levels would represent cord edema/ischemia/contusion.

3. Fracture of the lamina of the C4 vertebra bilaterally and the spinous process.

4. A left paracentral disc herniation at the C5-C6 level with mild indentation upon the left C6 nerve root.


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