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Date : 00.00.00

Name of the Patient : Abc Xyzqim Almn / M / 30 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

H/O spinal surgery 1 year ago. Details not available.
C/O weakness of BLE and BUE with 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 axial images.

4 mm thick T1 Weighted coronal images.

OBSERVATION :

There are post-operative changes in the posterior soft tissues at the C1, C2 and C3 vertebral levels with susceptibility artifacts.

There is evidence of atlanto-axial dislocation with the atlanto-dens interval measuring approximately 11.0 mm.

A small hypointense area is seen within the cord on the T1 Weighted images at the C2 vertebral level. This turns hyperintense on the T2 Weighted images and would represent an area of myelomalacia.

There is beaking of the cerebellar tonsils.
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- 2 - Scan-00005


Small posterior disc bulges are seen at the C3-C4, C4-C5, C5-C6 and C6-C7 levels.

The cervical intervertebral discs show loss of water content.

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

IMPRESSION :

The MRI features are suggestive of :

1. Post-operative status.

2. Atlanto-axial dislocation with the atlanto-dens interval measuring approximately 11.0 mm.

3. Altered signal within the cord at the C2 vertebral level and which would represent an area of myelomalacia.

4. Beaking of the cerebellar tonsils.

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