hs/ke/nl/nl
Date : 00.00.00
Name of the Patient : Abc Xyzam N. Plmn / M / 47 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neckpain with radiation of pain to the RUE. Also C/O weak grip.
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.
Right paracentral and right postero-lateral disc herniations with large peridiscal osteophytes are seen to indent the right ventral aspect of the cord and the right C7 nerve root with right neural foraminal narrowing at the C6-C7 level.
A posterior disc herniation with peridiscal osteophytes is seen to indent the cord at the C5-C6 level. A small postero-central disc herniation is seen to indent the thecal sac at the C4-C5 level.
The C4-C5 and C5-C6 facet joints show mild degenerative changes.
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 :
The MRI features are suggestive of :
1. Right paracentral and right postero-lateral disc herniations with large peridiscal osteophytes are seen to indent the right C7 nerve root at the C6-C7 level.
2. Posterior disc herniation with peridiscal osteophytes at the C5-C6 level.
3. A small postero-central disc herniation at the C4-C5 level.