sb/ke/nl/rg.
Date : 00.00.00
Name of the Patient : Abc Xyzl lmn / M / 69 yrs.
Referred by : Dr. Abc Xyzagwati.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O progressive weakness of BUE and BLE since 4 months.
H/O discoidectomy at C3-C4-C5-C6 levels in 0000.
EXAMINATION :
M.R.I of the cervical spine was performed using the following parameters :
4 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 lordosis and loss of water content of the cervical intervertebral discs.
There is minimal forward translation of the C4 over the C5 vertebra.
There is evidence of discoidectomy at the C4-C5 and C6-C7 levels.
There is continuous ossification of the posterior longitudinal ligament over the C2 to C6 vertebral levels with slight compromise of the cervical canal over these levels.
A postero-central disc herniation with peridiscal osteophytes is noted at the C3-C4 level, indenting the dural theca anteriorly. There is also ligamentum flavum hypertrophy and resultant mild cord compression at this level.
The cervical spinal cord at the C3-C4 level shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images which suggest cord edema/ischemia.
Posterior peridiscal osteophytes are noted at the C4-C5, C5-C6 and C6-C7 levels indenting the cervical spinal cord anteriorly. Neural foraminal narrowing is noted at the C5-C6 and C6-C7 levels bilaterally.
The facet joints at the C4-C5 level appear slightly hypertrophied.
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.
IMPRESSION :
1. Post-operative status.
2. Continuous ossification of the posterior longitudinal ligament over the C2 to C6 vertebral levels with slight compromise of the cervical canal over these levels.
3. A postero-central disc herniation with peridiscal osteophytes at the C3-C4 level, with ligamentum flavum hypertrophy and resultant mild cord compression at this level.
4. Cord signal alteration at the C3-C4 level suggests cord edema/ischemia.
5. Posterior peridiscal osteophytes at the C4-C5, C5-C6 and C6-C7 levels.