Date : 00.00.00
Name of the Patient : Abc Xyzen Ghadlmn / F / 46 yrs.
Referred by : Dr. Abc Xyzhranwala.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neckpain with pain radiating to the right shoulder.
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.
The cervical intervertebral discs show loss of water content with loss of normal lordotic curvature.
There is a right postero-lateral disc herniation with a large peridiscal osteophyte at the C5-C6 level with antero-lateral indentation of the thecal sac and right neural foraminal narrowing. Indentation upon the right C6 nerve root is noted by a disc fragment in the right neural foramen.
Small posterior disc bulge with peridiscal osteophyte is seen at the C3-C4 level. Small posterior disc bulge is also noted at the C4-C5 level.
The cervical vertebral bodies 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 atlanto-axial region and the cervico-medullary junction are unremarkable.
The base of the skull was screened with 5 mm thick T2 Weighted axial images which shows bilateral maxillary sinusitis, left more than right, inflammatory changes in the ethmoidal air cells and a Thornwaldts cyst. Probable enlarged adenoids are noted. The seventh and eighth cranial nerve complex are unremarkable, bilaterally. Note is also made of a giant cisterna magna.
A right postero-lateral disc herniation with a large peridiscal osteophyte at the C5-C6 level with a disc fragment in the right neural foramen with indentation upon the right C6 nerve root.