sb/hs/nl/nl
Date : 00.00.00
Name of the Patient : Abc XyzBalmn / M / 50 yrs.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neckpain radiating to BUE with paresthesias.
H/O C5-C6 discoidectomy with bone graft done in June 0000. C5-C6 and C6-C7 discectomy with bone graft and fixation with plate and screws done 1 1/2 months back.
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 T2 Weighted axial images.
OBSERVATION :
There is H/O spinal surgery with plating in the anterior cervical region. Susceptibility artifacts are hence noted over the C5 to the C7 vertebral levels. It is thus difficult to appreciate the cervical vertebral bodies and the disc spaces at these levels.
There is loss of water content of the rest of the cervical intervertebral discs.
A small postero-central protruded disc is noted at the C4-C5 level.
The cervical spinal cord at about the C5 and C6 vertebral levels shows an ill-defined hyperintense signal on the T2 Weighted images. This signal appears iso to hypointense to normal cord on the T1 Weighted images and may represent cord edema/ischemia/gliosis.
The visualized 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 with susceptibility artifacts over the C5 to C7 vertebral levels and resultant degradation of the images at these levels.
2. Altered cord signal at the C5 and C6 vertebral levels may represent cord edema/ischemia/gliosis.
As compared to the previous MRI dated 00.00.0000, a second surgery has now been performed with anterior fixation in the cervical region as described. The signal change in the cervical cord is largely unchanged though it now appears more diffuse at the C5 and C6 vertebral levels.