sb/hs/rg/nl
s Date : 00.00.00
Name of the Patient : Abc Xyzhi Bhojglmn / M / 55 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neck pain with stiffness of the neck since 3 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 loss of water content of the cervical intervertebral discs.
Posterior peridiscal osteophytes with posterior disc bulges are noted at the C4-C5, C5-C6 and C6-C7 levels indenting the cervical spinal cord anteriorly. Ligamentum flavum hypertrophy is also noted at these levels as well as at the C3-C4 level.
A left postero-lateral (foraminal) disc herniation is noted at the C5-C6 level narrowing the left neural foramen at this level. Facetal hypertrophy is also noted at this level.
Postero-lateral disc herniations are seen to narrow both neural foramina at the C6-C7 level.
The cervical vertebral bodies show focal ill-defined hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images, which appears hypointense to normal marrow on the T1 Weighted images. Suspicious hyperintense signal on the
Fast Scan (T2 *) images is noted in the lamina of C5 (scan 105.14). There is however no pre or paravertebral soft tissue lesion identified.
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 :
1. Posterior peridiscal osteophytes with posterior disc bulges at the C4-C5, C5-C6 and C6-C7 levels with ligamentum flavum hypertrophy at these levels as well as the C3-C4 level.
2. A left postero-lateral (foraminal) disc herniation at the C5-C6 level with facetal hypertrophy and resultant narrowing of the left neural foramen at this level.
3. Postero-lateral disc herniations bilaterally at the C6-C7 level.
4. Focal altered signal in the cervical vertebral bodies is not specific for a single etiology. These changes may represent,
a. Multiple metastasis (in view of the age of the patient)/small cell tumors.
b. Multifocal tuberculosis.
c. ? Type I degenerative marrow changes.