hs/ke/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyzrnalmn / M / 60 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O stiffiness of all four extremities, loss of sensation over body, tremors in both hands and gait ataxia.
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.
FEW IMAGES SHOW PATIENT MOTION.
OBSERVATION :
A postero-central disc herniation with a peridiscal osteophyte is seen to indent the cord at the C5-C6 level. There is slight superior migration of this disc portion. The left joint of Luschka at the C5-C6 level shows degenerative changes with slight left neural foraminal narrowing.
A postero-central disc protrusion is noted at the C4-C5 level. Posterior disc bulges are seen at the C2-C3 and C3-C4 levels.
The cervical intervertebral discs show loss of water content. The cervical vertebral bodies show areas of fatty replacement of normal marrow.
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.
..2/.
- 2 - Scan-00002
The atlanto-axial region and the cervico-medullary junction are unremarkable.
IMPRESSION :
The MRI features are suggestive of a postero-central disc herniation with a peridiscal osteophyte at the C5-C6 level.