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Name of the Patient : Abc Xyz. Fernalmn / M / 53 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

Alleged H/O train accident at 10.30 am on 00.00.0000 with quadriparesis and bladder involvement 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.

OBSERVATION :

There is a large postero-central disc herniation with peridiscal osteophytes at the C3-C4 level with anterior compression of the spinal cord. The spinal cord over the C2-C3 to the C4-C5 level shows a hyperintense signal on the T2 Weighted and Gradient images, centrally, which is isointense to hypointense to normal cord on the T1 Weighted images. This would represent cord edema/contusion in the given clinical setting. Ligamentum flavum hypertrophy is also noted at the C3-C4 level.

A postero-central disc herniation is seen at the C5-C6 level with anterior compression of the cord. A small posterior disc bulge is noted at the C4-C5 level.

The cervical intervertebral discs show loss of water content.

Avulsion of the antero-inferior margin of C3 body is noted with suspicious fracture of the spinous process of C4 vertebra.
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Hyperintense signal is seen in the prevertebral soft tissue extending from the level of the clivus upto the C5 level on the T2 Weighted and Fast Scan (T2 *) images suggesting edema/contusion/hematoma.

Fatty changes are noted in the cervical bodies except C6 vertebral body.

Degenerative changes of joints Luschka at C5-C6, bilaterally and at the C4-C5 level on the left is noted. Facetal hypertrophy is noted at the C5-C6 level on the left.

The visualized paravertebral soft tissues are unremarkable.

The atlanto-axial region and the cervico-medullary junction are unremarkable.

IMPRESSION :

1. A large postero-central disc herniation with peridiscal osteophytes at the C3-C4 level with slight ligamentum flavum hypertrophy at that level.

2. Altered signal of the spinal cord over the C2-C3 to the C4-C5 level would represent cord edema/contusion, in the given clinical setting.

3. A postero-central disc herniation at the C5-C6 level.

4. Altered signal in the prevertebral soft tissues extending from the level of the clivus upto the C5 level suggests edema/contusion/hematoma.

5. Avulsion of the antero-inferior margin of C3 body with suspicious fracture of the C4 spinous process.

6. Degenerative changes of joints Luschka at C5-C6, bilaterally and at the C4-C5 level on the left with facetal hypertrophy at the C5-C6 level on the left.
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