ke/bv/nl/rg.
Date : 00.00.00
Name of the Patient : Abc Xyzm B. Klmn / M / 53 yrs.
Referred by : Dr. Abc Xyzagwati.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O pain with paresthesias in the left hand since August 0000. Now C/O weak grip.
C/O pain in the right shoulder since 2 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.
OBSERVATION :
The cervical intervertebral discs show loss of water content.
There is a left paracentral disc herniation at the C5-C6 level with mild left antero-lateral indentation of the cord and the left C6 nerve root.
Postero-central disc herniations are seen at the C3-C4 and C4-C5 levels with anterior indentation upon the spinal cord.
Posterior peridiscal osteophytes are noted at the C3-C4, C4-C5 and C5-C6 levels.
The cervical vertebral bodies show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
The cervical spinal cord reveals normal signal intensity.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
IMPRESSION :
1. A small left paracentral disc herniation at the C5-C6 level with antero-lateral compression of the spinal cord and the left C6 nerve root.
2. Postero-central disc herniations at the C3-C4 and C4-C5 levels.