sb/hs/nl/nl
Name of the Patient : Abc Xyzi Boblmn / F / 65 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
Alleged H/O fall on 00.00.0000 with progressive weakness of all four extremities.
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.
5 mm thick T2 Weighted axial images.
FEW IMAGES SHOW PATIENT MOTION.
OBSERVATION :
There is loss of normal cervical lordosis.
There is an anteriorly wedged C6 vertebral body with slight retropulsion. This vertebral body shows a hypointense signal on the T1 Weighted images and a subtle hyperintense signal on the T2 Weighted images. There is an increase in the interspinous distance at C5/C6 level with probable fracture of the right sided lamina and spinous process of the C5 vertebra. Ill-defined, hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images is noted in the posterior (paraspinal) soft tissues at the C5 and C6 vertebral levels and which may represent soft tissue edema/contusion. A similar signal is noted in the prevertebral space over the C5 to D1 vertebral levels which may suggest avulsion of the anterior longitudinal ligament from the vertebral bodies.
The cervical spinal cord at the C5 and C6 vertebral levels shows a subtle hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images which may represent cord contusion/edema, in the given clinical setting.
Subtle hypointense signal on the T1 Weighted images is noted adjacent to the superior cortical endplates of the C7 to D4 vertebral bodies. This signal appears iso to slightly hyperintense to normal marrow on the T2 Weighted images and may represent endplate fractures, in the given clinical setting. Hyperintense signal on the T2 Weighted images within the C5 vertebral body may represent bone edema.
Small, postero-central protruded discs with peridiscal osteophytes are noted over the C3-C4 to the C6-C7 disc levels.
The rest of the cervical vertebral bodies show spotty fatty marrow changes which may suggest osteoporosis. The intervertebral discs show loss of water content. The joints of Luschka are unremarkable.
Facetal hypertrophy is noted at the C3-C4 and C4-C5 levels on the left.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
IMPRESSION :
1. Anterior wedging of the C6 vertebral body with slight retropulsion and altered signal as described, most likely is post-traumatic in etiology, in the given clinical setting. Probable fracture of the right lamina and spinous process of the C5 vertebra is noted.
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2. Altered signal along the superior cortical endplate of the C7 to D4 vertebral bodies may represent endplate fractures superimposed on an osteoporotic spine (the upper cervical vertebrae show fatty marrow changes).
3. Altered cord signal over the C5 and C6 vertebral levels may represent cord contusion/edema, in the given clinical setting.
4. Small, postero-central protruded discs with peridiscal osteophytes over the C3-C4 to the C6-C7 disc levels.
5. Facetal hypertrophy at the C3-C4 and C4-C5 levels on the left.