Name of the Patient : Abc Xyz Upadlmn / M / 56 yrs.
Referred by : Dr. Abc Xyzrani.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
H/O anterior cervical discectomy at the C4-C5 and C6-C7 levels with fusion at the C4-C5 and C6-C7 levels in 0000.
Cervical laminectomy was done on 00.00.00.
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 evidence of laminectomy of the C4, C5, C6 and C7 vertebrae with post-operative changes in the posterior soft tissues. Also seen is fusion of the C4 and C5 and the C6 and C7 vertebrae with presence of bone grafts, more so on the left side. The C4-C5 and C6-C7 intervertebral discs are fused.
The cervical vertebral bodies show areas of fatty replacement of normal marrow.
Postero-central disc herniations are seen to indent the thecal sac at the C2-C3, C3-C4 and C5-C6 levels. A small postero-central disc herniation is seen at the C7-D1 level.
Small posterior peridiscal osteophytes are noted at the C3-C4, C5-C6 and C7-D1 levels.
There is ossification of the posterior longitudinal ligament over the C2 to C6 vertebral levels.
The cervical spinal cord over the C3-C4 to the C6-C7 levels appears smaller in diameter than normal. Hyperintense signal is seen within the cord on the T2 Weighted and Fast Scan (T2 *) images (hypointense on the T1 Weighted images) over these levels and this would suggest myelomalacia.
The cervical intervertebral discs show loss of water content.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
The MRI features are suggestive of :
1. Post-operative status.
2. Postero-central disc herniations at the C2-C3, C3-C4 and C5-C6 levels.
3. A small postero-central disc herniation at the C7-D1 level.
4. Myelomalacia over the C3-C4 to the C6-C7 levels.
5. Ossification of the posterior longitudinal ligament over the C2 to C6 vertebral levels.
As compared to the previous MRI dated 00.00.00 (Study No 0000), the patient is now status post-laminectomy. There is slight decrease in the degree of the disc herniation at the C3-C4 level. The rest of the features are largely unchanged.