sb/hs/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyzi Pralmn / F / 34 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neck pain with giddiness since 10 days.
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 loss of water content of the upper cervical intervertebral discs.
There is a congenital block C2/C3 vertebra with a hypoplastic C2-C3 disc. The C7 vertebral body is as marked on the film.
There is a right paracentral disc herniation at the C4-C5 level, indenting the cervical spinal cord anteriorly.
There is a fairly large right postero-lateral extruded disc at the C5-C6 level with cord compression, narrowing of the right neural foramen and indentation upon the right C6 nerve root at that level. Slight superior migration of the disc fragment is noted.
A minimal posterior disc bulge is noted at the C3-C4 level.
The cervical vertebral bodies and the remaining intervertebral discs show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
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The cervical spinal cord reveals normal signal intensity.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
IMPRESSION :
1. A congenital block C2/C3 vertebra with a hypoplastic C2-C3 disc.
2. A right paracentral disc herniation at the C4-C5 level.
3. A fairly large right postero-lateral extruded disc at the C5-C6 level with cord compression, narrowing of the right neural foramen and indentation upon the right C6 nerve root at that level. Slight superior migration of the disc fragment is noted.