sb/bv/rg/nl
Name of the Patient : Abc XyzMitlmn / M / 61 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
Alleged H/O fall with fracture in the LLE 1 1/2 years ago.
C/O radicular pain in BLE with tremors and occasional gait imbalance.
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 loss of normal cervical lordosis and loss of water content of the cervical intervertebral discs.
Posteriorly bulging discs with posterior peridiscal osteophytes are noted at the C3-C4, C4-C5, C5-C6 and C6-C7 levels indenting the dural theca anteriorly. Slight ligamentum flavum hypertrophy is also noted at these levels with obliteration of the posterior subarachnoid space.
Facetal hypertrophy is noted at the C3-C4, C4-C5 and C5-C6 levels bilaterally. Degenerative changes of the joints of Luschka is noted at the C3-C4 level bilaterally and at the C4-C5 and C5-C6 levels on the right.
A focal hypointense signal on all the pulse sequences is noted in the postero-inferior quadrant of the C4 vertebral body which may represent a focal degenerative change.
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The rest of the cervical vertebral bodies show spotty fatty marrow changes. 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.
IMPRESSION :
1. Posteriorly bulging discs with posterior peridiscal osteophytes at the C3-C4, C4-C5, C5-C6 and C6-C7 levels with slight ligamentum flavum hypertrophy at these levels.
2. Facetal hypertrophy at the C3-C4, C4-C5 and C5-C6 levels bilaterally with degenerative changes of the joints of Luschka at the C3-C4 level bilaterally and at the C4-C5 and C5-C6 levels on the right.