Date : 00.00.00
Name of the Patient : Abc Xyz Maklmn / M / 36 yrs.
Referred by : Dr. Abc Xyzpadhyaya.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neck pain radiating to the RUE with tingling since 3-4 days.
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.
There is loss of normal cervical curvature and loss of water content of the cervical intervertebral discs.
There appears to be continuous ossification of the posterior longitudinal ligament over the C4 and C5 vertebral levels.
A large posterior and right postero-lateral disc herniation is seen at the C5-C6 level with large posterior peridiscal osteophyte, anterior indentation of the cord and right neural foraminal narrowing. There is resultant indentation on the right C6 nerve root.
A left paracentral disc herniation is seen at the C4-C5 level with antero-lateral indentation of the thecal sac.
The cervical vertebral bodies show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
- 2 - Scan-00002
The cervical spinal cord reveals normal signal intensity.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
1. A large posterior and right postero-lateral disc herniation with large peridiscal osteophyte at the C5-C6 level and resultant indentation on the right C6 nerve root.
2. A left paracentral disc herniation at the C4-C5 level.
3. Ossification of the posterior longitudinal ligament over the C4 and C5 vertebral levels.