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sb/ke/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzik K. Almn / M / 54 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

Alleged H/O fall from a height 22 years ago.
C/O neck pain radiating to the LUE with paresthesias in the LUE and LLE and tremors in the LUE.

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 normal cervical lordosis and loss of water content of the cervical intervertebral discs.

There is a right postero-lateral disc bulge with peridiscal osteophytes at the C3-C4 level with slight right neural foraminal narrowing. Facetal hypertrophy is noted at this level.

A posteriorly bulging disc with a posterior peridiscal osteophyte is noted at the C4-C5 level.

A left paracentral and left postero-lateral disc herniation is noted at the C5-C6 level with left neural foraminal narrowing.

Bilateral far lateral disc herniations are noted at the C6-C7 level.
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Degenerative changes of the joints of Luschka are noted on the right side at the C3-C4 level and at the C4-C5 level bilaterally.

The upper cervical vertebral bodies show fatty marrow changes.

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. A right postero-lateral disc bulge with peridiscal osteophytes at the C3-C4 level with facetal hypertrophy at this level.

2. A posteriorly bulging disc with a posterior peridiscal osteophyte at the C4-C5 level.

3. A left paracentral and left postero-lateral disc herniation at the C5-C6 level with left neural foraminal narrowing.

4. Bilateral far lateral disc herniations at the C6-C7 level.

5. Degenerative changes of the joints of Luschka on the right side at the C3-C4 level and at the C4-C5 level bilaterally.




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