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sb/ke/rg.

Name of the Patient : Abc Xyzh Bholmn / M / 35 yrs.
Referred by : Dr. Abc Xyz
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O neck pain with pain radiating to the RUE.

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 normal cervical lordosis and loss of water content of nearly all the cervical intervertebral discs except the C4-C5 and C7-D1 discs.

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

There is a fairly large left paracentral disc herniation at the C5-C6 level with left neural foraminal narrowing and mild indentation on the left C6 nerve root. Slight superior migration of the disc fragment is noted. Degenerative changes of the joint of Luschka on the left is noted at the C5-C6 level.

A right paracentral and right postero-lateral disc herniation is noted at the C6-C7 level with slight right neural foraminal narrowing.

Slight facetal hypertrophy is seen at the C3-C4 level bilaterally.


The upper cervical vertebral bodies show spotty fatty marrow changes.

The rest of 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.

IMPRESSION :

1. A fairly large left paracentral disc herniation at the C5-C6 level with left neural foraminal narrowing and mild indentation on the left C6 nerve root. Slight superior migration of the disc fragment is noted.

2. A right paracentral and right postero-lateral disc herniation at the C6-C7 level with slight right neural foraminal narrowing.

3. Small postero-central protruded discs with peridiscal osteophytes at the C3-C4 and C4-C5 levels.

4. Degenerative changes of the joint of Luschka on the left at the C5-C6 level and facetal hypertrophy at the C3-C4 level bilaterally.



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