ke/sb/rg/nl
Date: 00.00.00
Name of the Patient : Abc Xyzath lmn / M / 55 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O acute onset of weakness of BLE 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 :
There is straightening of the cervical spine with loss of water content of the cervical intervertebral discs.
Slight retrolisthesis of the C5 over the C6 vertebral body is noted.
There is ossification of the posterior longitudinal ligament over the C5 to C7 vertebral levels.
A large posterior disc herniation with peridiscal osteophytes is seen at the C5-C6 level with anterior compression of the cord. The spinal cord at this level shows a subtle hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images and would represent cord edema/ischemia.
A left postero-lateral disc herniation is seen at the C6-C7 level with antero-lateral indentation of the cord and left neural foraminal narrowing. Altered cord signal is also noted at this level.
A right postero-lateral disc herniation is noted at the C4-C5 level with peridiscal osteophytes. There is antero-lateral indentation of the cord and indentation of the right C5 nerve root.
A small posterior disc bulge is seen at the C2-C3 level and a postero-central disc herniation at the C3-C4 level. The cervical facet joints appear hypertrophied.
Focal fatty changes are noted in the upper cervical vertebral bodies.
The rest of 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.
Screening, 5 mm thick Flair axial images of the brain reveal a small bright focus in the subcortical white matter in the right frontal region, ? ischemic focus (scan:102.14). Pansinusitis is also noted.
IMPRESSION :
The MRI features are suggestive of :
1. Slight retrolisthesis of the C5 over the C6 vertebral body.
2. A large posterior disc herniation with peridiscal osteophytes at the C5-C6 level with anterior compression of the cord. Cord signal alteration at this level would represent cord edema/ischemia.
..3/.
- 3 - Scan-00003
3. A left postero-lateral disc herniation at the C6-C7 level with left neural foraminal narrowing. Cord signal alteration is also noted at this level.
4. A right postero-lateral disc herniation with peridiscal osteophytes at the C4-C5 level indenting the right C5 nerve root.
5. A postero-central disc herniation at the C3-C4 level.
6. Facetal hypertrophy in the cervical region.
7. Ossification of the posterior longitudinal ligament over the C5 to C7 vertebral levels.