sb/ke/nl/rg.
Date : 00.00.00
Name of the Patient : Abc Xyzla A. Halmn / M / 48 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Cervico-dorsal Spine.
CLINICAL PROFILE :
C/O pain in the left paraspinal and interscapular region since 0000.
EXAMINATION :
M.R.I of the cervico-dorsal spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
7 mm thick T1 Weighted, T2 Weighted and Fast Scan (T2 *) axial images.
Vitamin E capsules were placed as markers at the site of pain.
OBSERVATION :
There is loss of water content of the visualized cervico-dorsal intervertebral discs.
Small postero-central disc herniation with peridiscal osteophytes is noted at the C5-C6 level indenting the dural theca anteriorly. Facetal hypertrophy is noted at this level, bilaterally.
Small posterior peridiscal osteophytes are noted at the D4-D5 and D5-D6 levels.
The visualized cervico-dorsal vertebral bodies and the intervertebral discs show normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The visualized cervico-dorsal spinal cord reveals normal signal intensity.
IMPRESSION :
1. Small postero-central disc herniation with peridiscal osteophytes at the C5-C6 level with facetal hypertrophy at this level bilaterally.
2. Small posterior peridiscal osteophytes at the D4-D5 and D5-D6 levels.