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hs/ke/rg/nl

Name of the Patient : Abc Xyz lmn / F / 58 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O pain in the entire back, radiating to the LLE and BUE with paresthesias in BUE since 4 months.

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 :

The cervical intervertebral discs show loss of water content. The C5-C6 intervertebral disc is decreased in height and shows calcium/vacuum phenomena.

A posterior disc herniation with large peridiscal osteophytes is seen to indent the cord and narrow both neural foramina at the C5-C6 level with canal stenosis.

A postero-central disc herniation with peridiscal osteophytes is seen to indent the cord at the C4-C5 level.

There is a small postero-central disc herniation with peridiscal osteophytes indenting the thecal sac at the C3-C4 level. There is a postero-central disc protrusion at the C2-C3 level.

The cervical spinal cord over the C3 to C6 vertebral levels shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images and this may represent cord edema/ischemia/gliosis.
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- 2 - Scan-00009


The cervical vertebral bodies show areas of fatty replacement of normal marrow. A hemangioma (hyperintense on all the pulse sequences) is seen within the C6 vertebral body.

There are anterior disc herniations with peridiscal osteophytes at the C4-C5 and C5-C6 levels.

The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.

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

IMPRESSION :

The MRI features are suggestive of :

1. A posterior disc herniation with large peridiscal osteophytes at the C5-C6 level with canal stenosis.

2. A postero-central disc herniation with peridiscal osteophytes at the C4-C5 level.

3. A small postero-central disc herniation with peridiscal osteophytes at the C3-C4 level.

4. A postero-central disc protrusion at the C2-C3 level.

5. Altered signal of the cervical spinal cord over the C3 to C6 vertebral levels suggests cord edema/ischemia/ gliosis.






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