Date : 00.00.00
Name of the Patient : Abc Xyzlmn / F / 40 yrs.
Referred by : Dr. Abc Xyzaubal / Dr. Abc Xyzrel /
Dr. Abc Xyzdi.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O backache and neck pain with pain radiating to the LUE and LLE with weakness. Also C/O gait imbalance.
H/O kochs spine (low back) in 0000. Received AKT.
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.
There is a postero-central disc protrusion at the C4-C5 level with anterior indentation of the thecal sac.
A small posterior disc bulge is seen at the C5-C6 level with posterior peridiscal osteophytes. The cervical intervertebral discs show loss of water content.
Diffuse fatty marrow changes are seen 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 cervical spinal cord reveals normal signal intensity.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
- 2 - Scan-00005
1. A postero-central disc protrusion at the C4-C5 level.
2. A small posterior disc bulge with posterior peridiscal osteophytes at the C5-C6 level.