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sb/bv/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzamani Ranlmn / M / 42 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O neck pain radiating to the RUE with paresthesias in the RLE since 1 1/2 months.
Alleged H/O fall 2 years ago with head injury.

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 :

There is loss of water content of the cervical intervertebral discs and loss of normal cervical lordosis.

There is ossification of the posterior longitudinal ligament over the C2 to C5 vertebral levels with resultant indentation on the dural theca anteriorly.

Small postero-central protruded discs are noted at the C3-C4 and C4-C5 levels.

A fairly large posteriorly herniated disc with peridiscal osteophytes is noted at the C5-C6 level with cord compression.

A fairly large posteriorly extruded disc is noted at the C6-C7 level with thecal sac compression. Slight superior migration of the disc fragment is noted.


The cervical spinal cord at the C5-C6 and C6-C7 levels shows a subtle hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images suggesting cord edema/ischemia.

Slight facetal hypertrophy is noted in the cervical region.

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. Ossification of the posterior longitudinal ligament over the C2 to C5 vertebral levels.

2. A fairly large posteriorly herniated disc with peridiscal osteophytes at the C5-C6 level with cord compression.

3. A fairly large posteriorly extruded disc at the C6-C7 level with slight superior migration of the disc fragment with cord compression.

4. Altered signal of the cervical spinal cord at the C5-C6 and C6-C7 levels suggests cord edema/ischemia.





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