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sb/hs/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz V. Palmn / M / 28 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O weakness of both shoulders with wasting (left more than right) since 6-7 months.

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.

SOME IMAGES SHOW PATIENT MOTION.

OBSERVATION :

There is loss of normal cervical lordosis and loss of water content of the cervical intervertebral discs.

There is a postero-central and right postero-lateral disc herniation with peridiscal osteophytes at the C5-C6 level, indenting the cervical spinal cord anteriorly. Slight right neural foraminal narrowing is noted at this level.

A small postero-central disc herniation is noted at the C3-C4 level.

A postero-central protruded disc is noted at the C4-C5 level.

There is a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images, best appreciated on the axial images, in the cervical spinal cord, anteriorly, at the C4, C4-C5 and C5-C6 levels. This signal appears isointense to normal cord on the T1 Weighted images and may represent cord edema/ischemia/gliosis.
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There is a slight loss of the normal anterior convexity of the spinal cord over the C3 to C6 vertebral levels.

There is slight anterior wedging of the C5 vertebral body without change in signal intensity.

The 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. A postero-central and right postero-lateral disc herniation with peridiscal osteophytes at the C5-C6 level.

2. A small postero-central disc herniation at the C3-C4 level.

3. A postero-central protruded disc at the C4-C5 level.

4. Altered signal in the cervical spinal cord, anteriorly, at the C4, C4-C5 and C5-C6 levels may represent cord edema/ischemia/gliosis. Also seen is a loss of the normal anterior convexity of the spinal cord over the C3 to C6 vertebral levels. Motor neuron disease should be excluded.




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