Name of the Patient : Abc Xyz K. Almaklmn / F / 50 yrs.
Referred by : Dr. Abc Xyz.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
Known C/O multiple sclerosis.
C/O difficulty in walking.
H/O anterior decompression with C5-C6 discectomy in 0000.
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.
After administration of contrast, 4 mm thick T1 Weighted sagittal images and 5 mm thick T1 Weighted axial images.
The cervical intervertebral discs show loss of water content.
The patient is status post C5-C6 discectomy.
There is an angular kyphus at the C5-C6 level with anterior discectomy and fusion. Posterior peridiscal osteophytes are seen at the C5-C6 level indenting the spinal cord anteriorly.
The cervical spinal cord at the C5 and C6 levels shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images and is isointense to normal cord on the T1 Weighted images. Smaller but similar areas are also seen within the
- 2 - Scan-00006
spinal cord centrally at the C2-C3 level, right postero-lateral aspect at the C3-C4 level and left postero-lateral aspect at the C7-D1 level. There is flattening of the ventral bulge of the spinal cord over the C3-C4 to the C6-C7 levels.
There are posterior disc herniations at the C2-C3, C3-C4, C4-C5 and C6-C7 levels with anterior indentation of the thecal sac. Mild left neural foraminal narrowing is noted at the C6-C7 level with degeneration of the joints of Luschka.
After administration of contrast, there is enhancement in the posterior aspect of the C5-C6 disc space which is reduced in height.
There is no other area of enhancement in the visualized cervical spinal cord or along the meninges.
Fatty changes are noted in the cervical vertebral bodies.
The remaining joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
1. Post-operative status.
2. Posterior disc herniations at the C2-C3, C3-C4, C4-C5 and C6-C7 levels.
3. Altered signal within the cervical spinal cord may represent demyelinating plaques as described in the given clinical setting of multiple sclerosis.
As compared to the previous MRI dated 00.00.00, no new lesions are identified on this study.