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PROVISIONAL REPORT

Date : 00.00.00

Name of the Patient : Abc Xyzhai Valmn / M / 42 yrs.
Referred by : Dr. Abc Xyzagwati.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O paresthesias in BUE with gait imbalance 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 a large left paracentral disc herniation at the C5-C6 level with left antero-lateral compression of the cord and left neural foraminal narrowing. Indentation upon the left C6 nerve root is noted. A small right postero-lateral disc herniation is also noted at this level with right neural foraminal narrowing.

A small posterior disc bulge is seen at the C4-C5 level.

The cervical spinal cord appears to be swollen over the C3 to the D3 vertebral levels and shows a hyperintense signal on the T2 Weighted and Gradient images over the C2 to the D3 vertebral levels. This is hypointense to the normal cord on the T1 Weighted images and would represent cord edema/ischemia.

Focal hypointense area on the T1 Weighted images is seen within the spinal cord at the C4 vertebral level which is seen to turn hyperintense on the T2 Weighted images and would represent an area of myelomalacia.
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The cervical intervertebral discs show loss of water content.

Diffuse fatty changes are seen in the upper cervical vertebral bodies.

The rest of the cervical vertebral bodies reveal normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.

The atlanto-axial region and the cervico-medullary junction are unremarkable.

IMPRESSION :

The MRI features are suggestive of :

1. A large left paracentral disc herniation at the C5-C6 level with indentation upon the left C6 nerve root.

2. A small right postero-lateral disc herniation at the C5-C6 level with right neural foraminal narrowing.

3. A small posterior disc bulge at the C4-C5 level

4. Altered signal of the cord over the C3 to the D3 vertebral levels would represent cord edema/ischemia.

5. An area of myelomalacia within the spinal cord at the C4 vertebral level.

As compared to the previous MRI dated 00.00.00, an area of myelomalacia at the C4 vertebral level is now well-defined. No other significant change is seen on this study.

Thanks for the reference.

Please send the films back for final report.
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