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ke/sb/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Gilmn / M / 66 yrs.
Referred by : Dr. Abc Xyzchale.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

H/O sudden onset of giddiness with fall and LOC for half an hour 2 days back.
C/O weakness of BUE and BLE since then.

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 are posterior disc bulges with large peridiscal osteophytes at the C3-C4, C4-C5 and C5-C6 levels with anterior indentation of the cord.

A small posterior disc bulge is also seen at the C6-C7 level. The cervical intervertebral discs show loss of water content.

The spinal cord at the C4 and C5 vertebral levels shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images. This is iso to hypointense to normal cord on the T1 Weighted images and would represent cord edema/contusion/ischemia.

Ligamentum flavum hypertrophy is seen over the C3-C4 to C6-C7 levels.




The C3-C4 and C4-C5 facet joints show mild degenerative changes. The right sided joint of Luschka at the C5-C6 level also shows degenerative changes, with right neural foraminal narrowing.

There is a small hyperintense area on the T1 Weighted images in the C6 vertebral body which is seen to turn hyperintense on the T2 Weighted images and may represent a degenerative cyst. Focal fatty change is also seen in the C6 vertebral body.

The rest of the cervical vertebral bodies show normal signal intensity. The remaining 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 :

The MRI features are suggestive of :

1. Posterior disc bulges with large peridiscal osteophytes at the C3-C4, C4-C5 and C5-C6 levels and a small posterior disc bulge at the C6-C7 level.

2. Altered signal of the spinal cord at the C4 and C5 vertebral levels would represent cord edema/contusion/ischemia.

3. Ligamentum flavum hypertrophy over the C3-C4 to C6-C7 levels.

4. Facetal arthropathy at the C3-C4 and C4-C5 levels and degenerative changes of the joint of Luschka on the right at the C5-C6 level.


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