Date : 00.00.00
Name of the Patient : Abc Xyz Kesalmn / M / 50 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervico-dorsal Spine.
CLINICAL PROFILE :
H/O being crushed between two vehicles on 00.00.00 with pain in the LUE and paresthesias since 1 month.
M.R.I of the cervico-dorsal 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 lordosis. The visualized cervico-dorsal intervertebral discs show loss of water content and the C5-C6 intervertebral disc is decreased in height.
A posterior disc herniation with peridiscal osteophytes is seen to indent the cord and cause bilateral neural foraminal narrowing at the C5-C6 level. The joints of Luschka on the left side show degenerative changes with narrowing of the left neural foramen.
A posterior disc herniation with peridiscal osteophytes is seen to indent the cord at the C6-C7 level.
Small posterior disc herniations with peridiscal osteophytes are noted at the C3-C4 and C4-C5 levels with mild indentation upon the cord.
A focal hypointensity on all the pulse sequences is seen within the C6 vertebral body on the left side and may represent a bone island.
The cervical vertebral bodies show areas of fatty replacement of normal marrow.
The dorsal spine was screened with 4 mm thick T2 Weighted sagittal images and shows a posterior disc bulge at the D12-L1 level. Slight facetal hypertrophy is seen on the right side at the D10-D11 level.
A soft tissue intensity lesion is seen in the left hemithorax and requires further evaluation.
The visualized dorsal vertebral bodies show normal signal intensity. The rest of the joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
The visualized cervico-dorsal spinal cord reveals normal signal intensity.
The cervico-medullary junction is unremarkable.
The MRI features are suggestive of :
1. A posterior disc herniation with peridiscal osteophytes at the C5-C6 level with degenerative changes of the joints of Luschka on the left side narrowing the left neural foramen.
2. A posterior disc herniation with peridiscal osteophytes at the C6-C7 level.
3. Small posterior disc herniations with peridiscal osteophytes at the C3-C4 and C4-C5 levels.