sb/ke/nl/rg.

Name of the Patient : Abc Xyzjay Jalmn / M / 29 yrs.
Referred by : Dr. Abc Xyzrani.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

Alleged H/O vehicular accident 1 year back with left brachial plexus injury.
C/O weakness of the left hand since then.

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.

3 mm thick T1 Weighted and T2 Weighted (with fat saturation) coronal images.

OBSERVATION :

There is loss of water content of the cervical intervertebral discs.

There is a fairly large, right paracentral disc herniation with peridiscal osteophytes at the C4-C5 level with right neural foraminal narrowing, indentation on the cervical spinal cord on the right and on the traversing right C5 nerve root.

There is small, postero-central protruded discs at the C2-C3, C3-C4 and C5-C6 levels.

A left paracentral peridiscal osteophyte is noted at the C6-C7 level indenting the dural theca anteriorly.


The facet joints at the C3-C4 and C4-C5 levels appear slightly hypertrophied.

The nerve root sleeves in the cervical region appear unremarkable on this study. No obvious brachial plexus injury is noted on this study.

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.

Small cervical lymph nodes are noted deep to the sternocleidomastoid muscles bilaterally.

IMPRESSION :

1. A fairly large, right paracentral disc herniation with peridiscal osteophytes at the C4-C5 level with right neural foraminal narrowing, indentation on the cervical spinal cord on the right and on the traversing right C5 nerve root.

2. Small, postero-central protruded discs at the C2-C3, C3-C4 and C5-C6 levels.

3. A left paracentral peridiscal osteophyte at the C6-C7 level.

4. Facetal hypertrophy at the C3-C4 and C4-C5 levels.

As compared to the previous CT myelogram dated 00.00.0000, the previously identified baggy nerve root sleeve/pseudomeningocele in the left neural foramen at the C6-C7 level is not well identified on this study.