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sb/hs/rg/nl

Name of the Patient : Abc XyzKhandelmn / M / 37 yrs.
Referred by : Dr. Abc Xyzrani.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O neck pain radiating to the RUE with paresthesias.
H/O transphenoidal excision of acidophilic macroadenoma in 0000.
Has received radiotherapy (26 sittings).

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 water content of the cervical intervertebral discs.

There is a postero-central disc herniation with peridiscal osteophytes, more to the right of the midline at the C6-C7 level indenting the dural theca and right C7 nerve root at this level. Slight degenerative changes of the joints of Luschka are noted at this level with mild bilateral neural foraminal narrowing.

Small postero-central disc herniations are noted at the C4-C5 and C5-C6 levels.

A small postero-central protruded disc is noted at the C3-C4 level.

Slight ligamentum flavum hypertrophy is noted at the C5 and C6 vertebral levels.
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Slight facetal hypertrophy is noted at the C3-C4, C4-C5 and C5-C6 levels.

The cervical vertebral bodies show normal signal intensity. The rest of the joints of Luschka and 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. A postero-central disc herniation with peridiscal osteophytes, more to the right of the midline at the C6-C7 level with slight degenerative changes of the joints of Luschka bilaterally at this level.

2. Small postero-central disc herniations at the C4-C5 and C5-C6 levels.

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