sb/bv/rg/nl

Name of the Patient : Abc XyzFanuswlmn / M / 42 yrs.
Referred by : Dr. Abc Xyzao.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O pain in the left shoulder, arm and left trapezius region since 8 days with inability to lift up the LUE.

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 reduction in height of the C5-C6 intervertebral disc and loss of water content of all the cervical intervertebral discs. There is also loss of normal cervical lordosis.

There is a fairly large, left postero-lateral disc herniation with peridiscal osteophytes at the C4-C5 level with indentation on the cervical spinal cord on the left and impingement of the left C5 nerve root. Superior migration of the disc fragment along the left postero-lateral margin of C4 is noted. There is also left neural foraminal narrowing. Slight facetal hypertrophy is also noted at this level.

There is a postero-central and right postero-lateral disc herniation with peridiscal osteophytes at the C5-C6 level with right neural foraminal narrowing. Slight facetal hypertrophy is noted at this level.

There is a postero-central disc herniation with peridiscal osteophytes at the C6-C7 level indenting the dural theca anteriorly.
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Small, postero-central protruded disc is noted at the C3-C4 level.

Degenerative changes of the joints of Luschka are noted at the C5-C6 level, bilaterally.

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.

Screening T1 Weighted coronal images of the left shoulder joint reveal mild degenerative changes along the inferior margin of the acromio-clavicular joint. No obvious tear of the tendinous insertion of the supraspinatous muscle is noted. The head of the left humerus and the gleno-humeral joints are unremarkable.

IMPRESSION :

1. A fairly large, left postero-lateral disc herniation with peridiscal osteophytes at the C4-C5 level with impingement of the left C5 nerve root and superior migration of the disc fragment along the left postero-lateral margin of C4 vertebra with slight facetal hypertrophy at this level.

2. A postero-central and right postero-lateral disc herniation with peridiscal osteophytes at the C5-C6 level with right neural foraminal narrowing and slight facetal hypertrophy at this level.

3. A postero-central disc herniation with peridiscal osteophytes at the C6-C7 level.