hs/ke/nl/nl
Date : 00.00.00
Name of the Patient : Abc Xyz Ilmn / M / 46 yrs.
Referred by : Dr. Abc Xyznshah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neckpain with pain radiating to the LUE with numbness.
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.
A posterior disc herniation with large peridiscal osteophytes is seen to indent the cord and the left C6 nerve root at the C5-C6 level.
A posterior disc herniation with peridiscal osteophytes, more to the left of the midline is seen to indent the thecal sac at the C6-C7 level.
A mild posterior disc bulge with small peridiscal osteophytes is noted at the C4-C5 level.
A right postero-lateral peridiscal osteophyte is noted at the C3-C4 level with slight right neural foraminal narrowing.
The cervical vertebral bodies show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
..2/.
The cervical spinal cord reveals normal signal intensity.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
IMPRESSION :
The MRI features are suggestive of :
1. A posterior disc herniation with large peridiscal osteophytes indenting the left C6 nerve root at the C5-C6 level.
2. A posterior disc herniation with peridiscal osteophytes, more to the left of the midline at the C6-C7 level.