Date : 00.00.00
Name of the Patient : Abc Xyz Fernalmn / F / 55 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neckpain with pain radiating to BUE (right more than left) with numbness since August 0000. H/O fall prior to this.
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.
The cervical intervertebral discs show loss of water content.
There is a right postero-lateral disc herniation with large peridiscal osteophyte at the C5-C6 level, causing bilateral neural foraminal narrowing and indentation upon the right C6 nerve root.
A small posterior disc bulge is seen at the C4-C5 level.
The joints of Luschka on the left side at the C3-C4 and C6-C7 levels show degenerative changes with mild left neural foraminal narrowing.
The facet joints on the left side at the C4-C5 and C5-C6 levels show hypertrophic changes.
Focal fatty changes are noted in the upper cervical vertebral bodies.
The remaining 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.
1. A right postero-lateral disc herniation with large peridiscal osteophyte at the C5-C6 level and indentation upon the right C6 nerve root.
2. Degenerative changes of the joints of Luschka on the left side at the C3-C4 and C6-C7 levels with mild left neural foraminal narrowing.