sb/hs/nl/rg.
Name of the Patient : Abc Xyz lmn / M / 38 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
H/O cervical spinal surgery on 00.00.00. Details not available.
C/O burning sensation in BLE with weakness.
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 slight loss of water content of the cervical intervertebral discs with evidence of discectomy at the C6-C7 level and susceptibility artifacts in that region.
There is seen a postero-central disc herniation with posterior peridiscal osteophytes at the C6-C7 level, slightly more to the right of the midline, indenting the dural theca, anteriorly. Degenerative changes of the joints of Luschka are noted, at this level bilaterally with resultant neural foraminal narrowing.
The cervical spinal cord at the C5 and C6 vertebral levels appears slightly smaller in calibre and shows a hypointense signal on the T1 Weighted images which turns hyperintense on the T2 Weighted images.
A postero-central disc herniation is noted at the C5-C6 level with indentation on the thecal sac.
A minimal posterior disc bulge is noted at the C4-C5 level.
The facet joints at the C4-C5, C5-C6 and C6-C7 levels appear slightly hypertrophied.
The cervical vertebral bodies appear slightly hypointense to normal marrow on the T1 Weighted images and which suggest a
preponderance of hematopoeitic marrow (? anemic).
The rest of 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 :
1. Post-operative status.
2. A postero-central disc herniation with posterior peridiscal osteophytes at the C6-C7 level, slightly more to the right of the midline with degenerative changes of the joints of Luschka at this level, bilaterally.
3. Atrophy of the cervical spinal cord at the C5 and C6 vertebral levels with altered signal suggests myelomalacic changes.
4. A small postero-central disc herniation with peridiscal osteophytes at the C5-C6 level.
5. Slight hypertrophy of the facet joints at the C4-C5, C5-C6 and C6-C7 levels.
As compared to the previous MRI dated 00.00.0000, the patient is status post-operative. Atrophy of the cord with myelomalacic changes is noted at the C5 and C6 levels. The extent of the edema/ischemia in the cervical cervical cord is however less on the present study.