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Date : 00.00.00

Name of the Patient : Abc XyzShlmn / M / 47 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

H/O fall on 00.00.0000.
C/O tingling sensation in the LUE and LLE since 1 month and difficulty in micturation and constipation since 1 week.

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 and Fast Scan (T2 *) axial images.

OBSERVATION :

The cervical intervertebral discs show loss of water content.

There is posterior disc herniation with (larger to the right of the midline) large peridiscal osteophytes at the C6-C7 levels, antero-lateral indentation of the cord and right neural foraminal narrowing. Indentation upon the right C7 nerve root is noted. A small left postero-lateral disc herniation is also seen at this level with antero-lateral indentation of the cord, left neural foraminal narrowing and indentation upon the left C7 nerve root.

The spinal cord at the C6-C7 level is compressed and shows a subtle hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images. This is isointense to the normal cord on the T1 Weighted images and would represent cord edema/contusion (in the given clinical setting of trauma)/ischemia.

Small postero-central disc protrusions are noted at the C2-C3, C3-C4 and C4-C5 levels with anterior indentation of the thecal sac.
..2/.





The C3-C4, C4-C5, C5-C6 and C6-C7 facet joints on the left show mild degenerative changes.

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

The atlanto-axial region and the cervico-medullary junction are unremarkable.

IMPRESSION :

1. A right posterior disc herniation with large peridiscal osteophytes at the C6-C7 levels compressing the spinal cord and the C7 nerve roots.

2. Subtle altered signal of the spinal cord at the C6-C7 level would represent cord edema/contusion/ischemia.




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