Date : 00.00.00
Name of the Patient : Abc Xyza P. Klmn / F / 50 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neck pain with tingling on the left side of face.
C/O rheumatoid arthritis since 10 years.
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.
There is atlanto-dens subluxation with the atlanto-dens interval mesuring approximately 6.0 mms.
The odontoid process in its superior aspect shows irregular outline with destruction of its cortex along its anterior and left lateral margin. An intermediate signal intensity lesion on the T1 Weighted images is seen in the left lateral mass of the atlas, the C2 vertebral body and in the periodontoidal region. This is seen to turn heterogeneously hyperintense on the T2 Weighted and Gradient images and may represent pannus in the given clinical setting. There is slight extension of the lesion in the left lateral epidural space at the C2 level (se/im 105/8).
There are small posterior disc bulges with peridiscal osteophytes at the C3-C4, C4-C5, C5-C6 and the C6-C7 levels. The cervical intervertebral discs show loss of water content.
The rest of the cervical vertebral bodies show spotty fatty marrow changes. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
- 2 - Scan-00000
The cervical spinal cord reveals normal signal intensity.
The cervico-medullary junction is unremarkable.
1. Irregularity of the odontoid process with altered signal in the left lateral mass of the atlas, the C2 vertebral body and periodontoidal space may represent pannus in the given clinical setting.
The possibility of this being an infective or neoplatic process may be considered as a differential diagnosis, though less likely.
2. Small posterior disc bulges with peridiscal osteophytes at the C3-C4, C4-C5, C5-C6 and the C6-C7 levels.
3. Atlanto-dens subluxation with the atlanto-dens interval mesuring approximately 6.0 mms.