ke/sb/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyzi Maklmn / M / 55 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O gait ataxia since 3 months.
EXAMINATION :
M.R.I of the cervical spine was performed using the following parameters :
4 mm thick T1 Weighted, T2 Weighted and Flair sagittal images.
5 mm thick T1 Weighted and Fast Scan (T2 *) axial images.
OBSERVATION :
There are small posterior disc bulges with peridiscal osteophytes at the C5-C6 and C6-C7 levels.
There is a subtle, hyperintense signal on the Fast Scan (T2 *) images in the cervical spinal cord, more so posteriorly, over the C2 to C5 vertebral levels. This signal appears isointense to normal cord on the T1 Weighted images.
The cervical intervertebral discs show loss of water content.
The cervical vertebral bodies show spotty fatty marrow changes. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
There is no cord compression.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
Incidental note is made of mild prominence of the cerebellar folia.
The dorsal spine was screened with the help of 4 mm thick T2 Weighted sagittal images which shows a small posterior disc herniation with peridiscal osteophytes at the D9-D10 level.
IMPRESSION :
1. Small posterior disc bulges with peridiscal osteophytes at the C5-C6 and C6-C7 levels.
2. Subtle altered signal in the cervical spinal cord, more so posteriorly, over about C2 to C5 vertebral levels is not specific for a single etiology. Such changes may be seen in subacute combined degeneration of the cord.