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Date : 00.00.00

Name of the Patient : Abc Xyzs Shlmn / M / 50 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O tremors all over the body since 4 months.
C/O neckpain and low back pain with pain radiating to BUE, giddiness and gait ataxia.

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.

There is a fairly, large right paracentral extruded disc at the C5-C6 level with cord compression and right neural foraminal narrowing. Slight inferior migration of the disc fragment is noted. The cervical spinal cord at the C6 vertebral level shows a hyperintense signal on the T2 Weighted images which suggest cord edema/ischemia. A left postero-lateral peridiscal osteophyte is also noted at this level with left neural foraminal narrowing.

Small postero-central disc herniations are noted at the C4-C5 and C6-C7 levels and a posterior disc bulge at the C3-C4 level.

Degenerative changes of the joints of Luschka are seen at the C3-C4 and C4-C5 levels bilaterally, at the C6-C7 level on the right and at the C5-C6 level on the left.


Slight facetal hypertrophy is noted at the C3-C4, C4-C5 and C5-C6 levels bilaterally.

There is slight ligamentum flavum hypertrophy at the C4-C5, C5-C6 and C6-C7 levels.

The cervical vertebral bodies show preponderance of hematopoeitic marrow with diffuse fatty changes in the upper cervical vertebral bodies. The visualized pre and paravertebral soft tissues are unremarkable.

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

IMPRESSION :

1. A fairly, large right paracentral extruded disc at the C5-C6 level with cord compression and cord signal alteration at the C6 vertebral level suggesting cord edema/ischemia. A left postero-lateral peridiscal osteophyte is also noted at this level.

2. Small postero-central disc herniations at the C4-C5 and C6-C7 levels and a posterior disc bulge at the C3-C4 level.

3. Degenerative changes of the joints of Luschka at the C3-C4 and C4-C5 levels bilaterally, at the C6-C7 level on the right and at the C5-C6 level on the left.

4. Slight facetal hypertrophy at the C3-C4, C4-C5 and C5-C6 levels bilaterally.




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