Date : 00.00.00
Name of the Patient : Abc XyzKumlmn / M / 19 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
H/O giddiness with loss of consciousness for an hour on 00.00.00.
Now C/O loss of taste.
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.
4 mm thick T1 Weighted coronal images.
4 mm thick T2 Weighted sagittal images in flexion and extension.
There is occipitalization of the atlas.
There is atlanto-dens subluxation with the atlanto-dens interval measuring approximately 9.0 mm. Resultant indentation upon the spinal cord, anteriorly by the posterior margin of the dens is seen. The cervico-medullary junction, however shows normal signal intensity. On the flexion images, there is slight increase in the atlanto-dens interval, which is reduced on the extension images.
There is a C5/C6 congenital block vertebra, with partial fusion, posteriorly.
Small posterior disc bulges are noted at the C2-C3 and C3-C4 levels. The upper cervical intervertebral discs show loss of water content.
The cervical vertebral bodies and the remaining intervertebral discs show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
The cervical spinal cord reveals normal signal intensity.
The cervico-medullary junction is unremarkable.
Incidental note is made of a retrocerebellar arachnoid pouch/mega cisterna magna.
The MRI features are suggestive of :
1. Occipitalization of the atlas.
2. Mobile atlanto-dens subluxation with the atlanto-dens interval measuring approximately 9.0 mms in the neutral position.
3. Block C5/C6 vertebra with partial fusion, posteriorly.